CAMP REGISTRATION | Walk with Autism

Participant First Name:

Participant Last Name:

Participant Birthday:

Month

Day

Year

Participant Preferred Color:

Participant Shirt Size:

Participant Preferred Snacks and Drinks (list dietary needs):

Participant Preferred Activities/Interests:

Participant Sensory Triggers (if any):

Participant Allergies:

Participant Medical Conditions or Disabilities:

Participant Physical Restrictions (if applicable):

Participant Preferred Method of Behavioral Support:

Strategies for Supporting Participant:

If "Other" is selected, please describe:

Participant Support Staff Needed:

1:1 Support

Small Group Support

No Support Needed

Other

If "Other" is selected, please describe:

Car Seat and Booster Seat Requirements (if applicable):

My child requires a car seat/booster seat and I will provide one.

My child does not require a car seat/booster seat based on state law and age/weight requirements.

Please provide any other relevant information about your child’s needs or preferences that will help the camp staff provide the best care and experience for your child:

Primary Emergency Contact Name:

Primary Emergency Contact Phone Number:

Primary Emergency Contact Email

Secondary Emergency Contact Name:

Secondary Emergency Contact Phone:

Authorized Pick-up Person: Name and Phone Number

I have completed the Release of Liability.

Encouraging Awareness and Acceptance of Autism
one step at a time

2025 Camp Connection Registration