TAPA Summer Registration

Child's Name

Age

Address

Enrolled in Program:
(name of school and/or program)

Name of Parent/Guardian

Address
(if different from above)

Phone

E-Mail

Person to contact in case of an emergency

Emergency Contact Number

Special Needs
Please note: Children using wheelchairs must be able to transfer by themselves or the family must provide a personal attendant. Personal attendants also need to send in a registration form.

Cerebral PalsyDown SyndromeAutismAutism SpectrumLearning disabilities/delaysSeizuresMy child requires a 1-on-1 assistantOther

If you check other please describe
(including physical disabilities)

Favorite Activities

Dance/MovementYogaActingArtMusic

Number of Weeks for Enrollemnt
$500 for full days $250 week for 1/2 days

One WeekTwo WeeksThree Weeks

Camp Selection

Full Day ( 9am-3 pm)Half Day (9 am -12 pm)

or Reset

The Theresa Alessandra Russo Foundation | 250 Lido Blvd. | Lido Beach, NY 11561 | (516) 432-0200 | Fax (516) 432-0449