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Camp Kanya
Jewels Twirling Academy
Spring Break Camp Registration
Please complete the application below
Please call to learn about our sibling discount.
Spring Break Camp Registration(2024)
2024 Spring Break Camp Registration
Please fill out all information.Â
What is your child’s first name?
What is your child’s last name?
Which site will your child attend?
- Select -
Dream Center Optimist and Arts Academy
Dream Center at Southside Cultural Arts/Ft. Lauderdale
Dream Center at Holiday Park/Ft. Lauderdale
Will your child require transportation assistance?
- Select -
YES
NO
What grade is your child in for the 23-24 school year
- Select -
Pre K
K
1
2
3
4
5
What is your child's date of birth
What is your child's age
What is the sex of your child?
- Select -
Female
Male
What school does your child currently attend?
Is your child proficient in English
- Select -
YES
NO
Other languages spoken in your home
- Select -
Haitian
Creole
Spanish
Other
Which race/ethnicity best describes your child?
- Select -
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Haitian
Hispanic
White / Caucasian
Other
What is your street address?
In what city do you live?
Does the child have health insurance?
YES
NO
What is the name of your medical insurance carrier?
What is the medical insurance carrier number?
List any allergies, illnesses, medicines, behaviours, or other important medical issues that we should know about concerning your child. If there are none, write none
Primary Parent/Guardian's Full Name
Primary Parent/Guardian's Cell Number
Primary Parent/Guardian's email address
Secondary Parent Guardian's Full Name
Secondary Parent/Guardian's Cell Number
Emergency Contact Name
Emergency Contact Relationship to Child
Emergency Contact Number
We want to help your child in the best way possible and grant the best experience. Please tell us the way your child communicates. Check all that apply
Speaks and is easily understood
Speaks but is difficult to understand
Uses communication devices like pictures or a board
Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking
Uses sign language
Using signs that are not words like laughing or grunting
What, if any, help does you child receive at this time? Check all that apply
Behavioral therapy or services
Counseling or emotional concerns
Daily medication (not including vitamins)
Occupational Therapy
Physical Therapy
Special Educational Services in school
Speech/Language Therapy
None of the above
What conditions does your child have that are expected to last for a year or more? Check all that apply
Autism spectrum disorder
Problems with aggression or temper
Problems with attention or hyper activity (ADHD)
Developmental delay (only if under age 5)
Intellectual/Developmental disability (if over age 5)
Hearing impairment or deaf
Learning disability (school age)
Medical condition or illness
Physical disability or impairment
Problems with depression or anxiety
Speech or Language condition
Vision impairment or blind
None of the above
Do any of the conditions marked above make it harder for your child to do things that other children can't do?
- Select -
YES
NO
Who referred you to the program? (PLEASE STATE THE PERSON'S NAME IF APPLICABLE)
Typing your name in the box below constitutes an electronic signature
Section Break
Some description about this section
To support your child, what are of assistance might your child need help in
No extra help is needed
Holding a pencil, crayon, etc.
Sports or physical activities like running, or other gross motor tasks
Managing feelings and behavior
Academic learning or reading activities
Adapting activities to take into account a visual or hearing impairment
Using assistive devices like wheelchair, crutches, braces, or walker
Personal services like help with feeding or toileting
If there is anyone who is NOT to pick up the child, list the names. If this doesn't apply, put n/a
Other than the child's Parents, who is permitted to pick up the child? List names
Spring Break Registration Fee
Register Single Student ($110)
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