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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
*
Male
Female
Other
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
*
Yes
No
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
home
Services
Counseling Services
>
Adults
Teens & Adolescents
Children
Couples
Contract Services
School Services
Forms & FAQs
Locations
Statesboro
Atlanta
Pooler
Telehealth Team
Contact Us
Join Our Team