MOXIE Beginner Camp Application | Inclusion Moose Jaw

Summer 2026 - Beginner MOXIE Application

This application is for the Summer 2026 Beginner MOXIE program. Please complete all required sections. If you need help at any time, contact Inclusion Moose Jaw at programmanager@inclusionmoosejaw.org or 306-692-6943.

Beginner MOXIE

Ages: 3–7
Support Ratio: 1:1
Sessions:
- Morning: 9:30 am – 12:00 pm
- Afternoon: 12:30 pm – 3:00 pm
- Full Day (Ages 6 & 7 only)
Dates of Program: July 2-3, July 6-10, July 13-17, July 20-24, July 27-31, August 4-7

Early drop-offs and late pick-ups are not available. Late pick-ups may result in a fee.

Dates of Attendance

Session Selection

Which session are you applying for?

Morning (9:30 am – 12:00 pm)

Afternoon (12:30 pm – 3:00 pm)

Full Day (Ages 6 & 7 only)

Camper Information

Participant's Full Name

Date of Birth

Year

Month

Day

Parent(s)/Guardian(s)

Street Address

City

Postal Code

Primary Phone (Home or Cell)

Work Phone

Email Address

Emergency Contact

Emergency Contact Name

Relationship to Participant

Emergency Phone (Home or Cell)

Work Phone

School & Reporting Information

2026–2027 School Name

Team Lead (if applicable)

Teacher (if applicable)

Medical & Safety Information

Medical Alerts (if any)

Seizure Type

Seizure Information (if applicable)

Describe what happens during a seizure.

Typical length of seizure

Recovery time needed

Allergies

Does the participant have allergies?

Yes

No

Allergen(s)

Reaction

Treatment / Medication

Additional Support Information

Important information staff should be aware of (e.g., flight risk, sensory needs, mobility supports, food concerns)

If medication will be administered during program hours, a medication consent form must be completed.

Transportation

Transportation Selection

I will arrange my own transportation

I would like the enhanced transportation option ($40/day, if available)

Funding Information

Please select all that apply.

Cognitive Disability Strategy (CDS) funding

Autism Individualized Funding (Saskatchewan)

Other funding source (please specify)

Other funding source (if selected)

I do not have funding or need more weeks than my funding allows and would like to discuss a subsidy.

Membership (Optional)

Optional $10 Membership Fee

Yes, I would like to include the $10 membership fee

No, not at this time

Note: $5 stays with Inclusion Moose Jaw. $5 supports Inclusion Saskatchewan.

Program Guidelines

(Checkboxes – ALL Required)

I have provided school contact information so program plans and progress can be shared, if applicable.

I understand that all required consent forms must be completed and submitted with this application.

I understand that transportation to and from the program is not provided, and transportation during program hours is by walking.

I understand that the optional $10 membership fee is not payable through funding.

I understand that this application and all required forms must be submitted by April 10, 2026, and that late applications may be accepted only if space is available.

Consent & Permissions

(Checkboxes – ALL Required)

I give permission for my child to attend the Summer 2026 Beginner MOXIE program.

I understand that all fees and arrangements are due by April 26, 2026.

I understand that fees are non-refundable once staffing has been confirmed.

I understand that Inclusion Moose Jaw is not responsible for lost or broken personal items.

I give permission for Inclusion Moose Jaw to access information from my child’s school or support programs as needed.

Photo Permission

Photo Use Permission

Yes, photos may be used

No, photos may not be used

Signature

Parent/Guardian Full Name

Signature (Required)

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Date

Year

Month

Day