2024 LAKESHORE SUMMER CAMP REGISTRATION

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All information provided in this registration will be treated confidentially and not shared with a third party.

I am: *

New to LakeShore

A returning camper

CAMPER INFORMATION

Camper's LAST Name: *

Camper's FIRST Name: *

Date of Birth: *

YYYY

Current Grade: *

PreK - 13

7th

8th

9th

10th

11th

12th

13th+

Graduated

School District / School: *

Avon

Avon Lake

Bay Village

Cleveland

Fairview

Keystone

Lakewood

Midview

North Ridgeville

North Olmsted

Olmsted Falls

Rocky River

Strongsville

Westlake

Other:

Required

Child's disability:

check all that apply

ADD / ADHD

Deaf / Hard of Hearing

Autism

Blindness / Low Vision

Cerebral Palsy

Traumatic Brain Injury

Developmental Delay

Down Syndrome

Multiple Disabilities

Medical Disability

Pervasive Developmental Delay

Physical Disability

Sensory Processing Disorder

Speech and Language Disability

Specific Learning Disability

Emotional Disturbance

Mowat-Wilson Syndrome

Other Health Impairment

Mutism

Other

Anxiety

If "Other", please specify:

Is there any information about your child you would like to share:

i.e. - academic level, strengths, talents, behaviors, fears,

PARENT INFORMATION

type "N/A" if not applicable

Mother's Name: *

Father's Name: *

PARENT CONTACT INFORMATION

type "N/A" if not applicable

Home Cell Phone: *

Mother Cell Phone: *

Mother Work Number: *

Mother Email Address: *

Father Cell Phone: *

Father Work Number: *

Father Email Address: *

HOME ADDRESS

Street # *

City *

State *

Zip Code *

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