Summer Camp Registration – Impact Academy

Checkboxes (copy) *

Session 1 – June 9, 2025 through June 20, 2025
Session 2 – June 23, 2025 through July 4, 2025*
Session 3 – July 7, 2025 through July 18, 2025
Session 4 – July 21, 2025 through August 1, 2025

Camp Hours will be 8:30 a.m. until 2:30 p.m. daily. Registration fee of $100 is due at the time of registration. Camp cost is $700 per child (per two week session). *Session 2 will be prorated to $630 due to being off July 4, 2025 for the holiday. Campers must pay for full sessions. No discount will be given for missed days during a session. Due to printing error on the original postcard, for any parent choosing to keep camper home on July 3, 2025, this session only will be prorated to $560. This proration is an exception to usual guidelines. Before and After Care is available for $95/Sibling fee of $60 per week. Before Care only is $40 per week. Drop in Rates: After Care $35 per day. Before Care is $20 per day. Credit card payments will be accepted with a 3.5% service charge. Payments can be made in person at one of our locations or contact Beth Santos to pay over the phone or email. Phone is (813)693-5101, Option 1, Extension 103. Email is beth@impactacademyschool.org.

Email *

Camper Name *

First

Last

Has the camper previously attended Impact Academy's Summer Camp? *

Yes
No

Parent Name(s) *

Parent Occupation(s) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

DOB *

Diagnosis(es) *

Primary Phone *

Secondary Phone

Current School *

Does student have: (Please check all that apply)

IEP
504 Plan

Please upload IEP/Behavior Plan

Click or drag files to this area to upload. You can upload up to 2 files.

Medical Insurance Company *

Policy Number

ABA Therapy Company *

Previously required 1/1? *

Yes
No

Is your child potty-trained? *

Yes
No

Does your child have a history of seizures? *

Yes
No

Date of last seizure, if applicable.

Does your child have pica? *

Yes
No

Is your child an elopement risk? *

Yes
No

Does your child have allergies? *

Yes
No

Allergies:

Does your child exhibit disruptive behavior? *

Yes
No

Does your child take medicine during school hours? *

Yes
No

List of current medications, if any.

Dietary Restrictions?

Additional Information?