“I’M INTERESTED!” FORM

mighty mouth kids camp

MULTI-DAY INTENSIVE FOR CHILDREN WITH SELECTIVE MUTISM

Interested families are encouraged to complete the form below. A member of our team will then send you a copy of our Camp Information Packet and schedule you for a free, 30-minute call with our Camp Director.

All information is kept strictly confidential. If this is an emergency, please do not complete this form and instead call 9-1-1 or go to your nearest emergency room.

What is your name?

What is your email address?

What is your phone number?

(###)

###

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What is your child's name?

What is your child's date of birth?

YYYY

Where do you live?

How did you hear about us?

What services, if any, has your child received for SM?

Is there anything else you'd like us to know before we speak with you?

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Yes, count me in!