Camp Chit Chat | Summer Speech Camp Registration

Guardian Information

First Name

Last Name

Cell Number

Relationship to Child

Secondary Emergency Contact

If someone other than the parent/guardian listed above should be contacted in case of an emergency, please provide their information. The parent/guardian listed above will be considered the primary emergency contact.

First Name

Last Name

Cell Number

Relationship to Child

Child Information

Are you registering more than one child?

First Name

Last Name

T-Shirt Size

Grade

First Name

Last Name

T-Shirt Size

Grade

First Name

Last Name

T-Shirt Size

Grade

School District

Please list any food allergies or dietary restrictions

Please List any Special Health Concerns or Medical Conditions

Will your child(ren) attend the morning or afternoon session each day?

Please indicate the number of children you are registering

Upload Speech Evaluation

Please provide a copy of your child's most recent speech evaluation to help us tailor their summer camp experience. Alternatively, you may email a copy to Rebecca Smith, Clinical Director (rpsmith@etbu.edu).
One file only.
100 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.

Liability Release and Medical Authorization

I have read and understand the Acknowledgement of Risk, Assumption of Liability, and Medical Authorization.

Photography and Media Release

I have read and understand the Photography and Media Release. If this box is left unchecked, I am indicating that my child(ren) should not be photographed, videotaped, or recorded during camp activities.

I certify that I have read the Liability Release/Medical Authorization and Photography and Media Release.

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Payment Information

Name as it appears on credit card

Phone number of name on credit card

total 0.00

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