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Bike Camp 2020
Little Steps Pediatric Therapy
41 Waukegan rd. Glenview
847-707-6744
info@littlestepspt.com
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* Indicates required question
Email
*
Your email
Childs Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Guardian Name
*
Your answer
Best Contact Number
*
Your answer
Home Address
*
Your answer
Email
*
Your answer
Current or Past Patient?
*
Yes
No
Required
What session will you be attending? (If you would like to sign up for more than one session, please select one time from session 1 and one from session 2)
*
Session 1A (3:30-4:30 June 8th-11th)
Session 1B (4:30-5:30 June 8th-11th)
Session 2A (3:30-4:30 July 13th-16th)
Session 2B (4:30-5:30 July 13th-16th)
Required
I acknowledge that I will need to bring my own bike and helmet to each day of camp.
*
Yes
Required
I would like to see if my insurance can be used for Bike Camp
*
Yes
No
I understand that if I am not using insurance, the full amount of Bike Camp is due by the 1st day of camp.
*
Yes
Required
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