YouthCares Summer Registration

YouthCares Summer Camp Registration

Summer camp registration is not complete until a registration form and a $50 registration fee is received to secure your child's slot reservation.
Please Select the summer camp/ camps your child will attend. *

STEAM Camp June 13- 17 Safety Camp June 20 - 24 Making Proud Choices/ Leadership Camp June 27 - July 1 Fun, Summer Fun Camp July 6 -8 Reading/ Literacy Camp July 11 - 15 All Summer Camps Girls Empowerment Camp June 1 - 3 ($50)
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Grade Attending in Fall 2022 *
Student Information
First Name *
Last Name *
Gender *

Female Male
Birth Date *

Month Day Year
Home Phone

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Medical Information : Preferred Hospital *
List of Allergies
Medical Conditions
Current Medications
Are there any accommodations or supports the student requires ?
Child's Shirt Size :
Parent/Guardian Information 1
Full Name *

First Name Last Name
Home

Area Code Phone Number
Cell *

Area Code Phone Number
Work

Area Code Phone Number
E-mail *
Address - Same As Child *

Yes No
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information 2
Full Name

First Name Last Name
Home

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
E-mail
Address - Same As Childs

Yes No
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Emergency Contact - Other than Parent/Guardian
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home

Area Code Phone Number
Cell *

Area Code Phone Number
Work

Area Code Phone Number
Authorized persons for pick up and phone numbers. *
COVID Liability Waiver The novel coronavirus, COVID-19, has been declared a worldwide pandemic by theWorld Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations,prohibited the congregation of groups of people. YouthCares has put in place preventative measures to reduce the spread ofCOVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. YouthCares has made an informed decision about preventative measures from such bodies as the CDC, State and local government, and amongst other agencies, the Mississippi Department of Health. That being said, all of our preventative measures which include but are not limited to hand washing requirements, sanitation requirements, mask wearing in certain circumstances, and other such measures cannot be exhaustively listed in this document but YouthCares is making its best effort to protect all individuals involved from risk of contracting COVID-19. Should you have further questions about specific measures that YouthCares has put in place, please contact us at your convenience. Further, attending YouthCares could increase your risk and your child(ren)’s risk of contracting COVID-19.By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19by attending YouthCares and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at YouthCares may result from the actions, omissions, or negligence of myself and others, including, but not limited to, YouthCares employees, volunteers, and program participants and their families.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at YouthCares or participation in YouthCares Childcare programming ("Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless YouthCares its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions,omissions, or negligence of YouthCares, its employees, agents, and representatives,whether a COVID-19 infection occurs before, during, or after participation in YouthCares program.

Yes No
I, , the parent of a child/children at YouthCares agree to the following:I understand that my child(ren) whose name(s) are listed below may be photographed at YouthCares during normal hours, field trips, or activities. I understand that these photographs may be used in promoting child care services, either in print or on the internet.With my signature below I grant permission for my child(ren) to be photographed, or their images recorded for print or electronic use in promoting the YouthCares services. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment. I understand that there will be no payment for me or my child’s participation in this release

Yes No
Lability Release Form: In consideration of allowing the previously declared participant(s) to begin participation in YouthCares activities, while on the premises and property of the Center, the undersigned, for themselves, and/or being the legal and acting guardian of participant(s), acting for themselves and on behalf of the participant(s), release and hold harmless YouthCares, its owners, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises upon which YouthCares is conducted, or any premises under the control and supervision of YouthCares, its owners, or employees in route to or from any of the said premises, or while at any premises or place when activities sponsored by or participated in by YouthCares, its owners, or employees.

Yes No
My Products
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Camp Registration Fee $ 50.00
Camp registration fee includes each camp participants t - shirt and activity fee.

Quantity

Girls Empowerment Camp $ 50.00

Total $ 0.00
I, the parent/guardians have read and understand the contents of the Parent Handbook. I understand that the school reserves the right to amend policies and procedures when necessary, and that I will abide by changes. Any changes made to the Handbook will be distributed by YouthCares

Yes No

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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YouthCares Summer Camp Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Emergency Contact - Other than Parent/Guardian