FREE Summer Camp
Going online for summer fun and catching up
Student Information
Student Name
First Name
Last 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.
Grade going into
School Last Attended
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent(s)/Guardian(s) Information
Parent(s) / Guardian(s) Information (Please list in order of whom to contact first)
Name
Phone Number
Email
Address
Employer
Additional Information and Consent
PARENT/GUARDIAN CONSENT FOR VIDEO/AUDIO CONFERENCING, SUCH AS ZOOM. This parental consent notice is provided to inform you that your child/children will be participating in video/audio conferencing for the purpose of providing a fun and educational experience online in both large group sessions as well as 1 on 1 tutoring.
Yes, I understand and consent for the use of video/audio conferencing using zoom
No, I do not consent.
PHOTO/VIDEO RELEASE I hereby give permission for images of my child, captured during Summer Camp through video, photo and digital camera, to be used solely for the purposes of promotional material and publications, and waive any rights of compensation or ownership thereto.
Yes, I give permission
No, I do not give permission
Camp may be online. Will your child have access to the internet?
Yes
No
Would you be interested in connecting your child with an additional academic mentor? This will include enrichment activities and 1 on 1 follow up during the school year.
Yes
No
Date of Registration
-
Month
-
Day
Year
Date
Signature
Submit
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