Rainbow Tree - Registration Form

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WELCOME TO RAINBOW TREE! We are so excited to see you at camp!

Email *

Do you give permission to communicate via text message should something come up? *

Yes

May we contact you via email regarding your child? *

No I do not give permission for email communication.

Yes I give permission for email communication.

Camper's First Name *

Camper's Last Name *

Child's Date of Birth *

YYYY

Age of Child

Gender

Male

Female

Non-Binary

Other:

Clear selection

Winter Play Group Come Build a Snowman January 2024 Age 3-7

Winter Peer Group 9-12 years Wednesdays 4:10-5:10 p.m. Starts End of November

Handwriting Camp OR Handwriting Enrichment Private Sessions

All Boys TEEN Survive & Thrive Retreat

All Girls Social Awareness Camp - Summer

Brain Boost Nature Play (June)

Brain Boost Nature Play (August)

Find Your Rhythm First Level

Find Your Rhythm Next Level

Triple "S" Social Connection Camp Boys & Girls.

Fall Nature Therapeutic Play Group 3.5 -7 years - November 4, 2023

Other:

Required

Emergency Contact/Liability Docs/Permission Docs

The below information will be utilized in replace of an electronic signature. By clicking the agree boxes, you will be agreeing to the liability information and permission document details. All details of the below can be viewed under the Frequently Asked Question page on the website. https://www.rainbowtreetherapies.com/pages/liability-documents

First Name of Parent/Caregiver

Last Name of Parent/Caregiver

Street Address

City

State

Zip Code

Primary Contact- Name & Phone Number

Name of Emergency Contact (in the event you cannot be reached)

Emergency Contact's Phone Number

RELEASE OF LIABILITY *

Please review details of liability by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents

I have read the liability information and agree to its contents.

Required

PHOTO RELEASE *

Please review details of photo release by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents

I GIVE consent to take photos.

I do NOT give consent to take photos.

CHALLENGING BEHAVIOR PLAN *

Please review details by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents

I have read the information on the challenging behavior plan and agree to its contents.

Not Applicable for Parent Camp

CONSENT FOR MEDICAL TREATMENT *

Please review details of medical treatment form by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents

I give CONSENT for life saving medical treatment.

I do NOT give consent for medical treatment. I will describe below my treatment wishes.

If you checked I do NOT give consent to medical treatment, please provided a brief explanation for wishes for medical treatment.

Therapeutic Riding and Animal Assisted Therapy Release *

Please review details by clicking link: https://www.rainbowtreetherapies.com/pages/liability-documents

I have read the release of liability and hold harmless document AND agree to its contents for my child and/or my entire family. .

Required

Physical and/or Dietary Restrictions

PLEASE DESCRIBE.

Allergies (seasonal, food, insect)

Please describe and treatment protocol.

Medications & reason for taking.

Has your child ever had a seizure? Have you as a parent camper ever had a seizure?

Yes

Clear selection

Areas of special need, challenge or significant medical condition?

In respect for cultural sensitivity, please provide any information regarding cultural factors such as traditions, beliefs, or cultural background that we should be aware of when supporting your child.

Does your child have an IEP, receive OT, PT or Speech or have any other specialized support?

IEP

Speech

Counseling

Not Applicable

Other:

If yes to receiving any of the above, what is the focus of those services?

Please describe your child's special or specific interests, strengths and talents or anything else you would like us to know about your amazing child. Examples: Loves to create, build, sing, dance, read, be outdoors, interact with animals, run, laugh, be helpful. Include any specific interests as well. Thank you!

Please identify your families level of nature connection.

We get outdoors in nature 1-2 times per week.

We get outdoors in nature 3-4 times per week.

We get out 5 or more times per week.

We would love to get outdoors more but it happens very sporadically as a family.

Clear selection

Please check all that may describe your child:

Overall, my child is developing in typical progression without any noted concerns

Speaks negatively about self often - expresses feeling like a failure

Has a history of trauma

Has difficulty with articulation of speech or communicating with others

Has trouble using hands (fine motor skills) in play or other tasks such as dressing and eating.

Tends to over-react to sensory stimulation (example: touch/noise/movement)

Can be slow to warm up to new situations

Has difficulty coping - often feels stressed or worried or anxious

Can have difficulty making friends

Can be impulsive at times which impacts safety or following directions

Has difficulty with gross motor skills: can appear clumsy or off balance

Can have difficulty transitioning

Will sometimes avoid activities that are perceived as too hard

Has identified learning challenges

Other:

What are your GENERAL goals for your child when attending camp? (check all that apply). REMINDER: This is not private therapy but we do acknowledge your hopeful outcome of this experience at Rainbow Tree.

To support handwriting skills in private sessions.

To have a sense of belonging and connection with peers

To connect with peers to support development of friendship skills

To participate in a group format demonstrating skills like turn taking, singing together or greeting others

To enhance play skills with loose parts/unstructured play or structured play activities

To Increase independence by being away from home

To Increase confidence and self esteem through participation in meaningful activities

To Increase leadership skills

To Increase self awareness to cope with big emotions

To increase resilience through risk taking in the outdoors

To Increase physical stamina and endurance when navigating outdoor terrain

To Increase nature connection as a way to appreciate nature more.

To Increase safety awareness when playing outdoors

Other:

“I understand that Rainbow Tree Therapies, LLC will maintain my privacy to the highest standards. I understand that personal information will not be shared with anyone not affiliated with Rainbow Tree Therapies, LLC. I understand that personal information received through this registration will only be shared with professional staff and volunteer staff at Rainbow Tree to ensure the safety of my child and to ensure my child receives appropriate support needed while at camp." *

Yes

Do you wish to be added to the mailing list to be updated on future events? *

***Your email address will not be used for any purpose other than to provide you with information. At any time, you can be removed from the mailing list.

Yes

I am already subscribed.

Required

Please tell us how you heard about Rainbow Tree Therapies, LLC! (friend, social media, website, google search, social worker, school based therapist) *

What social media platforms do you primarily use?

Facebook

Instagram

TikTok

Snapchat

YouTube

Twitter

I am not on social media - I prefer email for communication

Submit

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