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2012 Summer Therapy C.A.M.P
(Children Actively Making Progress)
June 11 – July 11

Monday - Wednesday 9:00 AM– 12:00 noon
Contact: Dumas Therapy, 3203B Vineville Ave., Macon, GA  31204 (478) 737-9759

Registration Form
(Use this to register and pay online)

The summer camps are for children ages 5 to 11 years old (kindergarten to 5th grade). Camp sessions are limited to 30 children. Students will be divided among four groups with a camp leader in each group. The registration fee is $45.00 (non-refundable) and the camp fee is $215.00 for the summer. Children will receive occupational therapy, speech therapy, social skills training, play skills, reading, math, and arts/crafts activities. Scholarships and sponsorships are available to help cover the camp fee. Please inquire for more information about financial assistance. Brochures can be downloaded from this page. REGISTRATION DEADLINE: June 1. Sessions will be filled in the order in which registrations are received. Please send a snack and drink with your child each day.

Your email address:

Child’s information: (Register separately for each child.)
Last name: First name: MI: D.O.B.:
Home address: City: State: ZIP:
Type of autism: Diagnosis date/age:
Verbal: | Potty trained:

Health services information
Child’s doctor: Clinic: Phone:

Special medical needs or concerns:

Food allergies:

Parent or guardian’s information (Please indicate the preferred phone number to reach you.)
Mother’s name: Home #:
Address (if different): State: ZIP:
Work #: Cell #:
Father’s name: Home #:
Address (if different):
State: ZIP:
Work #: cell #:
Emergency contact
Person 1 - Name: Phone:
Person 2 - Name: Phone:
Medical Release:
I authorize emergency medical treatment for
in the event a parent/guardian or emergency contact cannot be reached in a timely manner.
Click to accept: (required)

Therapy Services Agreement:
I (parent) agree to have my child receive occupational therapy and speech therapy services during the camp.  I also understand that a physician prescription is required for therapy and that therapy services only will be billed to my insurance company(s). I authorize the release of any medical information or other documents necessary to process a claim for therapy services.  I certify that all information is correct.  I hereby assign payment for all medical benefits payable for occupational therapy services directly to one of the company’s names listed: Dumas Therapy, Kids-N-Action Pediatric Therapy, or Massage Education Network.  Also, I have read this financial policy and accept responsibility for treatment costs not covered or reimbursed by my insurance company.

Click to accept: (required)

Camp T-shirt ($10), if desired, please indicate size:

Attendance Policy:
Children will need to be present and in attendance for the camp.  He/She will only be allowed three absences before their slot will be filled.  Please provide a doctor’s excuse for any illnesses that may occur.  Please provide one week's notice for planned family vacations.

Click to accept: (required)

(cannot be submitted until required boxes are checked)