Worthington Summer
Camp Registration

Camper Name:*
Parent/Guardian Name:*
Address:*
Home Phone:*
-
Mobile Phone:
-
E-mail:
Date of Birth:*
 / 
 / 
Camper's age:*

Please fill out the form to the best of your ability. Your details will help us determine if we can accommodate your needs for summer camp. 

Disability (Primary and Secondary)*
Strengths/Capabilities*
Interests, activity preferences, reinforces*
Physical limitations/supports required*
Toileting needs*
Behavior concerns/On a behavior plan*
Verbal threats or inappropriate language*
Transitions to and from activities*
Other behaviors not previously discussed above
Placement during the academic year*
Supports and/or services received in the home/school/community during the academic year*
Does your child have any medical concerns (i.e. seizures, diabetes, or other medical needs requiring attention)? Please be aware that Boundless does not have a full time nurse available for intensive needs.*
Communication needs:*
Any activity restrictions? *
Allergies and/or dietary restrictions*
Eating skills*
Toileting skills*
Dressing skills*
Presenting problem (Please select all that apply)
Please include details about the presenting problem(s).*
Camp payment options*
If you selected "other," please explain
Weekly Registration

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Worthington Campus

445 E. Dublin Granville Road
Worthington, OH 43085

614-436-7837

info@iamboundless.org

Newark Campus

140 W. Church Street
Newark, OH 43055

740-334-4056

info@iamboundless.org

West Carrollton Campus

700 Liberty Lane
West Carrollton, Ohio 45449

937-247-2400

info@iamboundless.org