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.
What reading skills do you think your child needs to improve? Check all that apply.

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
Is your family gross monthly income limit below $3,625 a month? (check one)

YesNo
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 zoomNo, 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 permissionNo, I do not give permission
Camp may be online. Will your child have access to the internet?

YesNo
Attendance is extremely important for the success in Reading Camp? Can you ensure that your child will attend Camp daily? Transportation is NOT provided.

YesNo
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.

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