Summer Camp Registration Summer Camp Registration Step 1 of 4 25% To enroll your child in Raphael Academy’s summer camp please complete all sections of this registration form. Registration is processed on a first come, first-serve basis.Child's basic informationChild's name* First Middle Last Date of birth* MM slash DD slash YYYY Age* Gender* Residential address* Street Address City 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 State ZIP Code Mailing address, if different from residential address Street Address City 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 State ZIP Code Phone*Alternate phoneCurrent school/program* Address* Street Address City 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 State ZIP Code Grades attended* Please attach a copy of your child’s current IEP.*Max. file size: 50 MB.Parent/Guardian Contact InformationParent/Guardian Name* First Last Relationship to child* Address, if different from child's Street Address City 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 State ZIP Code Home phone*Mobile phone*Work/alternate phoneEmail* Occupation Location of work I have another parent/guardian to add* Yes No Parent/Guardian 2 Name* First Last Relationship to child* Address, if different from child's Street Address City 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 State ZIP Code Home phone*Mobile phone*Work/alternate phoneEmail* Occupation Location of work Emergency ContactEmergency Contact Name* First Last Relationship to child* Address* Street Address City 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 State ZIP Code Home Phone*Mobile Phone*Work/Alternate PhoneEmail* Occupation Location of work Student ProfilePlease indicate whether your child exhibits any of the following behaviors so that we may provide a positive experience for all of the attendees of Summer Camp. If your child exhibits a behavior, please describe it; otherwise, please write "no".Self injurious behavior*Head banging, cutting, biting, etc.Aggression towards others*Biting, kicking, spitting, hitting, etc.Does your child have difficulty transitioning from place to place or from task to task?*Does your child exhibit Obsessive Compulsive issues (the need for things to be done a certain way)?*Does your child elope/flee/run away?*Does your child have sensory issues?*Sensitive to touch, sound, light, motion, etc.Does your child respond to their name (or a nickname) when called?*Please list any nicknames your child responds to.Does your child eat non-edible items (e.g. pebbles, erasers, etc.)?*Does your child require a one-on-one aide?*Please note that Raphael Academy does NOT provide one-on-one aides but allows students to have them up until they enter the 6th grade.Describe your child’s self care and toileting habits.*Teeth brushing, washing, toilet trained, etc. Medical NeedsDoes your child have a medical diagnosis? If yes, please describe below.*Please indicate your child’s health / medical needs other than the predominant medical diagnosis:*Does your child have allergies? If yes, please describe:*Does your child take any routine maintenance medication or supplements? If yes, indicate type and dosage:*Does your child require a special diet of any kind? If yes, please describe:*Describe any physical, psychological, behavioral and/or other needs, conditions, or concerns about the child that would assist our staff to best support the child.*Language & CommunicationIs your child verbal?*Does he/she request his/her needs and want to answer social questions etc.? Yes No Please describe your child’s verbal skills and any device used to aid with communication.*Likes & DislikesPlease describe your child’s preferred activities, interests and reinforcements:*Please describe activities that your child dislikes:*List any particular objects or situations which your child finds distressing.*e.g. crowds, unfamiliar situations, noises How did you hear about us?Check all that apply. Social media Search engine Online ad Print magazine ad Flyer Radio ad Peer referral Other Which network(s)? Which search engine? Where did you see the online ad(s)? In which magazine did you see the print ad(s)? Where did you see the flyer? On which radio station did you hear the radio ad? From whom did you hear about us? From what other source(s) did you hear about us? Application FeeTo complete the application process, please pay the non-refundable $50 application fee. Applications submitted without an application fee will be considered incomplete and will not be reviewed. Please enter the name, confirmation email, and billing address that should be associated with your application fee payment below. Once you submit this application, you'll be redirected to our PayPal online payment portal, where you may complete your non-refundable $50.00 application fee payment.Application Fee* Price: Name* First Last Confirmation Email* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SignaturesName of parent/guardian 1* First Last How would you like to provide your signature?* I would like to digitally sign my name. I would like to type my signature. Parent/guardian 1 signature*Use the box below to sign your name. Click the refresh icon at the bottom right to clear the box.Parent/guardian 1 signature*Type your full name. This will serve as your digital signature. Name of parent/guardian 2 First Last How would you like to provide your signature? I would like to digitally sign my name. I would like to type my signature. Parent/guardian 2 signatureUse the box below to sign your name. Click the refresh icon at the bottom right to clear the box.Parent/guardian 2 signatureType your full name. This will serve as your digital signature. CAPTCHANameThis field is for validation purposes and should be left unchanged.