Power Tools Registration

Online Registration - Power Tools for Living

PLEASE NOTE: If the camper is under 18 years old, this form must be completed by the Parent or Legal Guardian who has the right to make medical decisions for the child.

*This camp is specifically designed for students diagnosed with Autism Spectrum Disorder and related developmental disabilities.

* Indicates required field

Camper Name *

First

Last

Gender *

Date of Birth *

Age *

Street Address *

City *

State *

Zip Code *

Parent/Guardian Contact Name *

First

Last

Phone Number *

Email *

Address (if different from above) *

Please indicate the camp you are registering for: *

July 1st - 5th, 9 AM- 12 PM, Ages 10 to 17 July 8th-12th, 9 AM-12 PM, Ages 4 to 9

List any allergies (medication, food, or other): *

Is an Epi-pen required for any above allergies *

List any special needs/ considerations: *

List any dietary restrictions: *

Payment Information: Cost is $200 per person per camp. If the participant has a developmental disability and you need financial assistance please contact Easterseals Middle Georgia at (478) 275-8850 or Pineland BHDD at (912) 764-6906.

We are in network with certain insurance companies, but payment for camps will depend on benefits of your plan. All insurance companies we can take are listed on the flyer. If interested in using insurance, please provide the insurance information below.

*We will only charge the credit card for any amount that insurance doesn't cover. We will also contact you before charging the card.

Name on Credit Card *

Credit Card Number *

Expiration Date *

CVV Code *

By typing your name below you agree to allow Brave Tomorrow Counseling to charge your card $200 *

Insurance Company *

Member ID *

Comment *

Submit

Skills for Success:Power Tools for LivingREGISTRATION

Online Registration - Power Tools for Living

Skills for Success:
Power Tools for Living
REGISTRATION