Register for Camp SnowCubs by filling out the form below. Step 1 of 4 25% Child InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY 3 Days Session - $600/week* December 29 – 31 Requires 1-on-1 Aide - $450* Yes No Progress Report (ESY) - $135 Yes No Photo Album - $75 Yes No Requesting Morning Respite - $25/hr Yes No Requesting Afternoon Respite - $25/hr Yes No Medical InformationPhysician's Name First Last Physician's PhoneMedication Participant is takingMedication is treatment forPhysical RestrictionAllergies (Food & Environmental): Parents & Guardian InformationMother First Last Father First Last Guardian First Last Contact InformationMain ContactMotherFatherGuardianEmail* Phone HomePhone CellPhone WorkAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Time to ContactTime of day*Morning 8:30am - 12:00pmAfternoon 12:00pm - 5:00pmEvening 5:00pm - 8:30pmBest phone number*CellWorkHomeTerms & Conditions*Statement of Understanding & Behavior Policy: I (parent/guardian/caregiver of the registered camper) hereby make application to enroll my child in Peak Potential Therapy LLC’s camp program. I understand that the program is designed to provide a safe and positive environment for all participants. Campers are expected to: 1. Treat others with kindness and respect. 2. Use appropriate language. 3. Follow staff directions. 4. Refrain from aggression, bullying, or disruptive behavior. I understand that if my child engages in behavior that endangers others or significantly disrupts camp operations, they may be dismissed from the program without refund. Progressive discipline measures (warnings, parent communication, removal if necessary) will be applied where appropriate. Medical, Physical, and Psychological Disclosure I certify that I have disclosed all known medical, physical, and psychological conditions that may be relevant to my child’s safe participation in camp activities. I understand that failure to disclose such information may result in dismissal from the program without refund. Payment & Refund Policy - A $100 deposit per registered week is required to hold a camp spot. This deposit will be applied toward the final week’s tuition. - Deposits are refundable only if written notice of withdrawal is received before May 1st. - After May 1st, deposits and camp fees are nonrefundable, except in the case of program cancellation by Peak Potential Therapy LLC. - If Peak Potential Therapy LLC cancels a camp session, fees already paid will be refunded or credited. - Camp fees must be paid in full no later than 7 days prior to the camper’s start date. - No refunds or credits will be given once camp has begun, if a camper withdraws early, or if a camper fails to attend. Field Trip Permission I give permission for my child to participate in field trips during camp, which may include transportation by staff in approved vehicles. I understand that additional risks may be associated with field trips and that I will be notified in advance of specific outings. Emergency Treatment Authorization I authorize qualified and licensed medical professionals to provide emergency diagnosis and treatment for my child should a medical emergency arise, and reasonable efforts to contact me have been made. This authorization permits Peak Potential Therapy LLC staff to provide necessary emergency care prior to hospital admission. This does not waive any rights under Ohio law for claims of medical negligence. Assumption of Risk & Liability Waiver I understand that participation in camp activities carries inherent risks, including but not limited to: minor injuries (scrapes, sprains, insect bites), exposure to outdoor elements, allergic reactions, and risks associated with group activities and field trips. I agree to assume these inherent risks and, to the fullest extent permitted by Ohio law, release, indemnify, and hold harmless Peak Potential Therapy LLC, its owners, employees, and affiliates from claims or liabilities arising from my child’s participation in camp activities, except in cases of gross negligence or intentional misconduct. I acknowledge that program fees do not include accident or personal insurance, and I am responsible for providing such coverage if desired. I hereby agree to the Terms & Conditions.Publicity & Media Consent*I (parent/guardian/caregiver of the registered camper) hereby authorize Peak Potential Therapy LLC and affiliates, to obtain, store, publish and/or use (without payment) any photographs, slides, sound and/or video recordings made of my child for public relations, marketing/advertising and/or internal training purposes. Yes No Full Name*IMPORTANT: By typing your full name, you are providing your legal signature and affirmative consent to all waivers/releases. Campers will not be considered registered without their parent/guardian/caregiver's typed signature. Additional InformationHow did you hear about us?*ParentService ProviderPhysicianFunding AgencySchoolConferenceAurora Women's LeagueAutism SpeaksAutism SocietyNAANEOMilestonesPublicationFamily & Kids DirectoryFamily MagazineRadioeMailGoogleAsk.comYahooWebsite SearchOtherQuestions & CommentsCAPTCHA