HOSZ05 Adaptive Sports Camp Registration Screening Form

Adaptive Sports Camp
REGISTRATION SCREENING FORM

Para Español, seleccione del menú desplegable en la esquina superior derecha.

Please note that submitting this form is not a guarantee of registration
to a spot in the Hospital for Special Care Adaptive Sports program(s).
There will be a separate registration process to follow.

Name of Camper*

First NameMiddle NameLast Name

DOB of Camper*

Date

Age of Camper

Name of Parent/Guardian

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email for email notification

example@example.com

Text to above phone number providedCall to above phone number providedEmail to above email provided

YesNo

Primary diagnosis/disability

Traditional Adaptive Sports CampNeuro Diverse Track

Thank you for your interest! Someone from our program will be in touch soon.