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MOXIE JR & SR Camp

Summer 2026 -JR & SR MOXIE Application

This application is for the Summer 2026 JR & SR 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.

MOXIE

Ages: 8-22
Support Ratio: 1:1
Dates of Program: July 2-3, July 6-10, July 13-17, July 20-24, July 27-31, August 4-7,Aug 10-14

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

Session Selection

Which weeks are you applying for?

July 2-3

July 6-10

July 13-17

July 20-24

July 27-31

August 4-7

August 10-14

Participant 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 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