Spring Camp Cheerio 2015 Registration

Spring Camp Cheerio 2015 Registration

Last Name / First Name / Childs Age / Childs Grade / Allergies? / If HI, what amplification and communication modality is used? / Beginners Cued Speech Class? / Intermediate Cued Speech Class?
Do you or your child have any Special Accommodation requirements? If so, please list and explain.
Do you or your child need an Interpreter or Transliterator? If so, how often and in what settings?
Family name: ______
Complete Address: ______
Phone Number: Email Address:

T-Shirt Fundraiser for Family Scholarships- T-shirts are $15 each, Long Sleeve are $20 each
T-Shirt Orders: Adult: S____, M____,L____,XL____,2XL____ Youth: S____,M____,L____ Total Cost $____

Long Sleeve Orders:Adult: S____, M____,L____,XL____,2XL____ Youth: S____,M____,L____ Total Cost $____

Charges: Use the information below to total the cost of camp.Make Checks Payable to NCCSA
Mail Registration to: Stephanie Payonk: 409 S. Baldwin Ave, Spencer NC, 28159
You may also pay online at and email the registration form to
*Credit cards will be accepted*
1 Adult/ 1 Child / Family of 5
___ $295 -- Cabin / ___ $460 -- Cabin
___ $345 – Inn / ___ $555 -- Inn
Couple / Individual Adult (15+years)
___ $330 -- Cabin / ___ $195 -- Cabin
___ $375 -- Inn / ___ $235 -- Inn
___ $100 – Day Rate
Family of 3
___ $350 -- Cabin / Individual Child (6-14 years)
___ $405 – Inn / ___ $100 -- Cabin
___ $110 -- Inn
Family of 4 / ___ $80 – Day Rate
___ $405 -- Cabin
___ $495 – Inn
Use the Table below to calculate your camp cost! / **Registration Fee
____ $15 Feb 1-Feb 28
____ $25 March 1 –March 31
____ $35 April 1- 30
Family Total ______
Individual Total ______
* Additional Family Members Add as Individuals
* Children 5 and under are Free
Registration Fee +______
T-Shirts +______
Less Deposit
(minimum $75 - ______ / ** A non-refundable $75 deposit and Registration Fee is required at time of registration to reserve your spot!
Total cost of camp ______

• Scholarships are available on an as needed basis. Please see attached scholarship request form. $75 deposit and Registration fee at time of registration is still required to hold your spot. Scholarship awards will be determined by 4/30/2015. The scholarship application is available on our website at

• This year we are excited to be able to offer a "manual" track for the children's program. We are offering children sixth grade and up the option to choose this track and learn some basic sign language and cued speech skills as part of their class time. This group will function as any other group, and will still go to canoe, gym, etc.
• Please indicate your children’s names that would like to be in this track (6th grade and up only): ______

*No Pets Allowed

For Further Information, Please Contact:

Stephanie Payonk- 704-798-1094, or Courtney Branscome-