Upward Odyssey June 21-July 26 Registration Form Camper's Name(Required) Date of Birth(Required) Grade Entering(Required)5th Grade6th Grade7th Grade8th Grade9th Grade10th GradeCurrent School(s)(Required) Pediatrician Name(Required) Pediatrician Phone(Required)Please share any Diagnosis(Required)Does your child see a therapist or any other specialist? (If so, please make sure to click the link at the bottom of the page and fill out the entire release form)(Required) Yes No Does your child take any daily medications?(Required)Will your child need any medication administered to him during the day at Odyssey by our staff?(Required) Yes No Please share the name of the medication and any other information necessary:(Required)Allergy Information Please click here to add Allergy information Allergy Information(Required)Please explain what types of support you feel your child will need to have a successful experience:(Required)Please describe your child:(Required)Does your child have any fears/dislikes:(Required)Does your child have any sensory issues:(Required)Can he follow simple instructions(Required) Yes No What instructions does he best follow(Required) Verbal Gestures Written Picture (Visual aid) Other Other(Required)Is he aggressive in any way?(Required) Yes No Please explain aggressiveness(Required)Do you have any behavioral plans or instructions?(Required)Does your child have any special interests (i.e. sports, games, movies…)(Required)Please tell us any personal goals you would like your child to accomplish over the course of the summer(Required)Has your child attended any other camps in the past(Required) Yes No which ones and how was his experience?(Required)T-shirt Size(Required)Youth-SmallYouth-MediumYouth-LargeAdult-SmallAdult-MediumAdult-LargeMother's name(Required) Mother's cell #(Required)Mother’s Email(Required) Father's name(Required) Father's cell #(Required)Father’s Email(Required) Home Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Contact Name(Required) Emergency Contact relationship to participant(Required) Emergency Contact Number(Required)Participant's Insurance Information:Insurance Name(Required) Group Number(Required) ID Number(Required) Name on Card(Required) Phone number of Insurance Company(Required) Consent(Required) HEALTH AND SAFETYThe Parent or Guardian certifies that the child is healthy and able to participate in all Upward Community activities at the time of application. Parent/guardian gives permission to secure proper medical treatment in case of an emergency, when parent/guardian cannot be reached.Signature(Required) Reset signature Signature locked. Reset to sign again Consent(Required) WAIVER FOR PHOTO RELEASE:I give my consent for any photos/videos taken of my child involved in Upward Community programs to be used for, Upward Community and/or promotions or display.Signature(Required) Reset signature Signature locked. Reset to sign again Please click the link and fill out the release form if your child sees a therapist or any other specialist: https://practisforms.com/upwardcommunitychicago/forms/tazqe94x8vu June 21st – July 26th : $2100Payment Options(Required) Payment Option 1: (Full Payment $2100) Payment Option 2: (Three recurring $700 payments) Total HiddenPayment Mode Online Offline HiddenOffline Code Credit Card(Required)Card Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.
