Isaiah's Autism Family Camp: Session 3 Registration

This application provides you with an exclusive opportunity to enroll your family for Isaiah's Autism Family Camp: Session 3 (July 12th - July 14th, 2017). Please complete the online application, and send a $200.00 deposit per person. Once processed, the remaining balance owed will be confirmed via email.

*Please note: Deposits must be received within 14 days from the submission date in order to secure your space. VISA/ MC/ AMEX are accepted (3.5% processing fee applies) for the deposit by contacting Danielle Paskowitz at (949) 728-1000. Balance due must be paid by check.

Camper Information (Parent)
Please note ANY special information that we should be aware of, i.e. medical issues, required medication, allergies, and special needs with regards to diet, special social or physical needs:
($100.00 for primary parent chaperone or $400.00 for primary parent with surf instruction)
$
$
Secondary Parent
$ ($400.00 for secondary parent)
Camper with Autism
$
Additional campers (siblings or other family members) can be registered at $400.00 per person.
Additional Camper
$
Additional Camper
$ per person
Additional Camper
$
Insurance Information
Physician Information
Emergency Contact

Parents/Guardians - Please accept 'Assumption of risk and release waiver

On behalf of my child, I accept and assume any and all risks associated with his/her attendance and participation in the camp and its activities. I understand that my child should not attend the camp if he/she is not healthy. I understand that my child must abide by camp policies and the instructions of the camp staff. I agree that should my child be dismissed from camp no part of my tuition will be refunded. I understand that no reduction in the tuition will be made for late arrival, early departure, vacations, illness or injury. In the event that I can not be contacted in an emergency, I hereby grant PSC. (PSC) permission to give immediate treatment and/or take my child to a hospital emergency room. Permission is hereby granted for photographs and/or videos to be taken of my child at camp and PSC has the right to utilize these in our brochures, videos, slide shows, web site, and other camp materials. Permission is also granted for my child (if enrolled in Surf Camp) to attend all scheduled field trips. Knowing these facts and in consideration for your accepting my child's application, I, for myself, my child attending the camp, and anyone else who might claim on my or my child's behalf ("I"), hereby agree that neither PSC are responsible for accidents, injuries, and/or medical or dental expenses arising from my child's participation in the camp and, accordingly, I covenant not to sue, and waive, release, and discharge PSC, and anyone working on their behalf from any and all claims of liability or expenses of any kind or nature whatsoever arising out of or relating to my child's participation in the camp. I have carefully read all of the information in this application form and agree to all conditions.