Preschool Camp in Motion 2026

Parent Email Address

Camp information and updates will be communicated via email.

Camper Full Legal Name

Please list full name as will be listed on prescription for medical clearance to camp.

Camper Name for Nametag (If different from above)

Primary Diagnosis

Please list primary diagnosis to be listed on prescription for clearance to camp.  If primary diagnosis is not related to a physical limitation, please email campinmotion@ascension.org to ensure ability to participate.

Camper Birthday (MM/DD/YYYY)

Age at the Start of Camp

(must be age 2-5 years old at start of camp)

Therapy Goals

Please list any preferred therapy goals for camp.  (examples: PT-endurance, strengthening, balance, coordination, OT-social skills, dressing, ST-peer communication, social conversation)

Street Number and Street Name

Please list referring Physician Name
Please include both first and last name of physician.

Does your child have any areas of need in the following areas? (Please check all that apply)

Please list any allergies your child might have. 

If none, please write none to complete this section.

Please list any additional diagnoses that your camper has other than primary diagnosis (ie: autism, behaviors, seizure disorder, etc).  Please also indicate any items that may limit your camper or other campers from fully participating in the camp experience.

Please list any medications your child is taking and indicate which ones will need to be taken during the camp day. If no medications taken at camp, please write none.

Attendance Policy

I understand the importance of consistent daily attendance at Camp in Motion as it pertains to the physical and social aspects for my camper. I will make every attempt to attend daily as I understand other campers will be on a waiting list and may have attended this week. I will communicate needs to arrive late or leave early to camp staff in advance to ensure that all camper's have an ideal camp experience.

Insurance Policy

I understand that if I wish to bill insurance to cover the cost of Camp in Motion, that I must place my current therapy on hold for the week(s) attending camp, starting at the time of evaluation, to improve re-reimbursement for camp. I understand that I am responsible for my out-of-pocket expenses, deductible, and co-pay that have been un-met prior to camp.

Policy Holder's Name (If not billing insurance, please put N/A in the following section)

Insurance Group Number  (If not billing insurance, please put N/A in the following section)

Insurance Policy Number (If not billing insurance, please put N/A in the following section)