iamEffective Summer Reading Program

FREE Summer Camp IamEffective Reading Camp Registration Form
Location: Fairfield West Elementary School

4700 River Rd., Fairfield, OH 45014
Camp Dates: June 30, 2025 - July 25, 2025

Theme: Oh, the Places You'll Go Note: No camp held on July 4th or July 5th
Camp Time: 9am - 1pm
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Information
Student Name

First NameLast Name
Student book Interests - please let us know what genre or type of book your child finds exciting and enjoys. If they are not big readers just let us know what characters or type of entertainment they prefer to learn about.
Phonic and Phonemic AwarenessVocabulary and Sight WordsReading ComprehensionReading Speed and FluencyOther
Child's Known Allergies
Grade going into
School Last Attended
Gender
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent(s)/Guardian(s) Information
Parent(s) / Guardian(s) Information (Please list in order of whom to contact first)

Name

Home/Cell Phone Number

EmailAddress

Employer
Emergency Contact

Name

Home/Cell Phone Number

EmailAddress

Relationship
Additional Information and Consent
YesNo
Yes, I understand and consent for the use of video/audio conferencing using zoomNo, I do not consent.
Yes, I give permissionNo, I do not give permission
YesNo
YesNo
YesNo
Date of Registration

MonthDayYear
Parent/Guardian Name: First Name Last Name
By signing my name below, I acknowledge that I have read and understand the content included in this form and Effective Family Life and its Affiliates are held harmless from any and all liability.
Signature*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

FREE Summer Camp IamEffective Reading Camp Registration Form

Location: Fairfield West Elementary School

Camp Dates: June 30, 2025 - July 25, 2025

Camp Time: 9am - 1pm

Student Information

Parent(s)/Guardian(s) Information

Additional Information and Consent