Camp Registration Form - Summer 2024

Our Neurodiverse Student Skills Camp is designed to give students hands-on experience in some of the skills needed in day-to-day life as an adult, while providing a glimpse of life on a college campus through connecting with peers, current college students, and faculty.

For questions regarding this camp, please contact Dr. Devon Bowser, devon.bowser@waynesburg.edu.

1Basic Information > 2About the Student > 3Review Your Entry
Name of Person Completing this Form Name of Person Completing this Form First Last
Relationship to Student

Relationship to Student Self Parent/Guardian OVR Counselor Case Manager Other Other
Email (a copy of the completed form will be sent to this email address for your records)
We are offering two separate weekend camps in 2024. Please check the box for the preferred weekend.

We are offering two separate weekend camps in 2024. Please check the box for the preferred weekend. Friday May 17 - Sunday May 19 Friday May 31 - Sunday June 2
If there are no more spots available for the selected weekend above, would you like to be considered for the other weekend?

If there are no more spots available for the selected weekend above, would you like to be considered for the other weekend? Yes No
Student Basic Information
Student Name Student Name First Last
Student Preferred Name/Nickname
Student Date of Birth Student Date of Birth / MM / DD YYYY
Current Grade Level
Gender (Please choose one).

Gender (Please choose one). Male Female Non-binary Prefer to self-identify Prefer to self-identify
Ethnicity (Please choose one).

Ethnicity (Please choose one). Hispanic/Latino origin Not of Hispanic/Latino origin
Race (Please check all that apply).

Race (Please check all that apply). White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Pacific Islander Other Other
Student Address Student Address
Street Address Address Line 2 City State Zip Code
School District
Student Diagnosis
What level of support does this student currently have in educational settings?
Does this student have an active case with the Office of Vocational Rehabilitation (OVR)?

Does this student have an active case with the Office of Vocational Rehabilitation (OVR)? Yes No
Contact Information
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Phone Number Parent/Guardian Phone Number - ### - ### ####
Emergency Contact Emergency Contact First Last
Emergency Contact Phone Number Emergency Contact Phone Number - ### - ### ####
Additional Contact (if needed) Additional Contact (if needed) First Last
Additional Contact Phone Number (if needed) Additional Contact Phone Number (if needed) - ### - ### ####
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A special link to resume the form will be sent to your email address.

Camp Registration Form - Summer 2024

Camp Registration Form - Summer 2024

Student Basic Information

Contact Information