Ujima Summer Literacy Camp Registration Form

Ujima Summer Literacy Camp Registration

July 12-30, Monday-Friday, 8:00am-4:30pm Turning Point Church, 1722 N. National Ave. Half day of literacy instruction and enrichment + Half day of arts, fun, & games. We serve breakfast, lunch, and snack. There is NO COST to attend. Ujima Summer Literacy Camp is absolutely FREE. Register NOW! Space is Limited.
Student Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Student's Grade Fall 2021

KindergartenFirst GradeSecond GradeThird GradeFourth Grade5th Grade
School Attending Fall 2021
Does the student have any special medical or dietary needs? If yes, please describe. NOTE: We do not have a nurse on staff and cannot administer medication.
Does the student have any special education or learning needs? If yes, please describe.
Parent/Guardian Information
Name

First NameLast Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number
E-mail
example@example.com
What is the name of the elementary school closest to your home?
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship to Child
Phone Number
We often take lots of pictures and video to memorialize our experiences at summer literacy camp. These pictures may be used in promotional materials for Ujima and/or our partners.

I consent to my child being included in photos/videosI DO NOT consent to my child being included in photos/videos
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Ujima during the summer literacy camp. In exchange for the acceptance of said child’s participation by Ujima, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Ujima and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of participating in camp activities.

In case of injury to said child, I hereby waive all claims against Ujima including all affiliates, owners and lessors of premises used to conduct the event.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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