*Please note: If you are having problems with this form, please try the form again in a different Internet Browser. For example, if you are using Internet Explorer, please try again using Firefox, Chrome, or Safari.*

Parent Information

Name(s)*
Address:
Phone:*
-
E-mail:

Child Information

Name:*
Gender:
Birthdate:
 / 
 / 
Grade:

Presenting Concerns

Please describe or explain briefly.

Attention Issues:*
Social Issues:*
Compliance Issues:*
Self-Regulation Issues:*
History of Summer Camp Experience:
How did you find out about Camp Attaway?


Follow the directions to confirm you are a real person:
*Please note: If you are having problems with this form, please try the form again in a different Internet Browser. For example, if you are using Internet Explorer, please try again using Firefox, Chrome, or Safari.*