3203B Vineville Ave • Macon, GA • 31204
Phone: 478-731-5235  Fax: 855-574-5217
Email: thetherapyconnection@gmail.com

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2017 Summer Therapy C.A.M.P
(Children Actively Making Progress)
June 19 – July 12

Monday - Wednesday 9:00 AM– 12:00 noon
Contact: The Therapy Connection, 3040 Riverside Dr. Suite B-1
Macon, GA 31210 478-731-5235

The summer camp is for children with special needs. Camp sessions are limited to 25 children. Students will be divided among groups with a camp leader. The registration fee is $25.00 (non-refundable) and the camp fee is $100.00 for the summer. Children will receive occupational therapy, speech therapy, social skills training, play skills, reading activities and arts/crafts activities. Scholarships and sponsorships are available to help cover the camp fee. Please inquire for more information about financial assistance. You may download the flyer, which has a written form to mail in, or register online below. REGISTRATION DEADLINE: May 12. Sessions will be filled in the order in which registrations are received. Please send a snack and drink with your child each day.

Downloadable Forms:

Registration Form
(Use this to register and pay online)

Your email address:

Child’s information: (Register separately for each child.)
Last name: First name: MI:
Home address: City: State: ZIP:
Type of autism: Diagnosis date/age:
Verbal: | Potty trained:

Health services information
Child’s doctor: Clinic: Phone:

Special medical needs or concerns:

Food allergies:

Parent or guardian’s information (Please indicate the preferred phone number to reach you.)
Mother’s name: Home #:
Address (if different): State: ZIP:
Work #: Cell #:
Father’s name: Home #:
Address (if different):
State: ZIP:
Work #: cell #:
Emergency contact
Person 1 - Name: Phone:
Person 2 - Name: Phone:

Insurance Information
Policy Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Policy Holder Employer:

Medical Release:
I authorize emergency medical treatment for
in the event a parent/guardian or emergency contact cannot be reached in a timely manner.
Click to accept: (required)

Therapy Services Agreement:
I (parent) agree to have my child receive occupational therapy and speech therapy services during the camp. I also understand that a physician prescription is required for therapy and that therapy services only will be billed to my insurance company(s). I authorize the release of any medical information or other documents necessary to process a claim for therapy services. I certify that all information is correct. I hereby assign payment for all medical benefits payable for occupational therapy services directly to one of the company’s names listed: The Therapy Connection, Dumas Therapy, Kids-N-Action Pediatric Therapy, or Massage Education Network. Also, I have read this financial policy and accept responsibility for treatment costs not covered or reimbursed by my insurance company.

Click to accept: (required)

Attendance Policy:
Children will need to be present and in attendance for the camp. He/She will only be allowed three absences before their slot will be filled.  Please provide a doctor’s excuse for any illnesses that may occur.  Please provide one week's notice for planned family vacations.

Click to accept: (required)

(cannot be submitted until required boxes are checked)