Super Summer Camp Intake Form (The Club House)

After School (S.T.E.A.M.) Program Intake Form

Please help us ensure that your child has a successful summer experience by filling out this intake form. This information is kept in strict confidence.

Child ‘s First Name *

Child’s Last Name *

Parent/Guardian Full Name

Language Spoken in Child’s Home

Parent/Guardian Marital Status

Number of People in Household

Please answer the questions below to the best of your abilities.

Has your child had a summer camp experience before?

Have there been any changes in the family situation in the past year?

Is your child, or the family, receiving any special support with emotional concerns or behavior?

Does your child have any allergies or health issues that we should be aware of?

Has your child been identified as needing support or supplemental services, during the school year in any of the following areas: (Please check all that apply.)

Please describe or explain any area of services that you checked.

Does your child have an IEP or 504 Plan?

Is there anything you would like us to know about your child that will help us ensure he/she has a fun, well adjusted summer?

Parent/Guardian Signature

Date Signed:

Day Time Telephone Number

Evening Phone Number

Date Received in Somerset Academy, Inc. Office

Super Summer Camp Intake Form (The Club House)

For additional information on Somerset Academy Early Learning Center

Somerset Academy Early Learning Center

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