Summer Camp Registration – Impact Academy

Checkboxes (copy) *

Session 1 – June 1, 2026 through June 12, 2026
Session 2 – June 15, 2026 through June 26, 2026
Session 3 – June 29, 2026 through July 10, 2026
Session 4 – July 13, 2026 through July 24, 2026

Non-refundable registration fee of $150 is due at the time of registration. Camp cost is $750 per child per two week session. Campers must attend full sessions only. All summer camp fees MUST be paid two week prior to the beginning of the session(s) to be attended. Session 1 payment is due May 18, 2026. Session 2 payment is due June 1, 2026. Session 3 payment is due June 15, 2026. Session 4 payment is due June 29, 2026. All summer camp fees are non-refundable. Further information will be provided as it becomes available.

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

Drag & Drop Files, Choose Files 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?