Summer 2024 Group Interest form

Mini-Camp / Group Interest Form

Basic Information

MM slash DD slash YYYY
Has your child received services at SRC or The Southfield Center previously?(Required)

Please Select Your Child’s Availability for Half or Full Day Camps This Summer:

Week of 10 - 14 June
Week of 17 - 22 June
Week of 24 - 28 June
Week of 01 - 06 July
Week of 08 - 12 July
Week of 15 - 19 July
Week of 22 - 26 July
Week of 29 July - 02 August

Please Tell Us About Your Child's Social Strengths and Challenges:

Difficulty Maintaining Focus(Required)
Difficulty Initiating Conversations(Required)
Disengaged in Social Situations(Required)
Focused on Personal Wants / Not Interested in Collaboration(Required)
Concerned About the Perceptions of Others(Required)
Not Always Perceptive that Others are Not Enjoying Themselves(Required)
Trouble Being Flexible with Ideas(Required)
Sensory Overload in Social Situations(Required)
Has a Para Support Or Is In a Separate / SEL Classroom for Majority of School(Required)
Takes Several AP Courses / Has High IQ or Achievement(Required)
Generally Prefers Children Younger Than Themselves(Required)
Bonds Well with Adults(Required)

Please Select the Group Activities Your Child Would Enjoy:

Games (board / party / Video)(Required)
Community Service(Required)
Performing / Improv(Required)
Creative Writing(Required)
Art / Mural(Required)
Wellness / Yoga(Required)
If your child is new to our services, please email Christi ( with the subject line "New Group member registration." In the body of the email, include the following:
  • Child's full name
  • Date of Birth
  • Mailing address
  • Caregiver(s) full names
  • best phone number and email
This field is for validation purposes and should be left unchanged.