LOTC Bridge Camp Registration

Form Completed By

Relationship to the Child

Caregiver Information

First Name

Middle Initial

Last Name

Mobile Number (For status updates)

I do not have a mobile number

Do you know the Caregiver's email address?

Yes No

Caregiver's Address

Can't find your address? Enter it manually

Is the caregiver a licensed foster parent?

Caregiver's Licensing Agency

DSS Social Worker Information

First Name

Middle Name

Last Name

DSS Social Worker Phone

DSS Social Worker Email

DSS Social Worker County

Group Home Information

Group Home Name

Contact Person First Name

Contact Person Middle Name

Contact Person Last Name

Contact Person Phone #

Child Information

Child's First Name

Child's Last Name

What name does the child want to be called?

Child's Date of Birth

Child's Age at Camp (Auto-calculated)

Child's Placement Type

Child's Gender

Child's Ethnicity

Grade in School Fall of 2026

Child History

How long has the child been in current placement?

How long has the child been in foster/kinship care?

How many placements has the child been in?

Has the child attended an overnight summer camp before?

Does the child have any food allergies?

Does the child require a special diet?

Does the child currently take prescription medication?

Has the child received any psychological diagnoses?

Has the child ever seen a counselor/doctor/psychiatrist?

Has the child ever been hospitalized for psychological issues?

Does the child have behavioral difficulties?

Does the child have a Functional Behavioral Plan?

Does the child have sensory difficulties?

Does the child have social difficulties?

Does the child have nighttime issues?

Is there anything that would hinder camp experience?

Please describe the child's major strengths

Please describe the child's major difficulties

What else do we need to know about this child?

Confirmation & Consent

Email for confirmation

Phone # for text updates

By submitting this request, I agree to receive text messages and/or emails from Least of These Carolinas regarding this registration and Bridge Camp updates. I understand that completing this form does not guarantee a spot at Bridge Camp.

Please Read Before Completing This Form

Bridge Camp Registration