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SCAMP Application Form
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* Indicates required question
Scamper Last Name
*
Your answer
Scamper First Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Gender
*
Choose
Male
Female
Primary Certification/Impairment
*
Choose
Autism Spectrum Disorder
Cognitive Impairment
Deaf-Blindness
Emotional Impairment
Early Childhood Developmental Delay
Hearing Impairment
Severe Multiple Impairment
Specific Learning Disability
Speech and Language Impairment
Traumatic Brain Injury
Visual Impairment
Other Health Impairment
Additional Certification/Impairment (if applicable)
Your answer
Home School District
*
Your answer
School of Attendance
*
Your answer
Current Teacher's Name (2020-2021 School Year)
*
Your answer
Current Teacher's Email (to send Teacher Form that is usually included in the application packet).
*
Your answer
Most recent year attending Clarkston SCAMP
*
This will be the Scamper's first year
2019
2018
2017
Other:
Scamper's T-shirt Size
*
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Other:
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