Student Name
*
First Name
Last Name
Oxford Circle CCDA Summer Camp 2022
Welcome to the SPLASH Zone! A free 6-week in-person summer camp program from June 27th - August 5th, 2022 for students entering K through 5th grade in zip codes 19111, 19149, and 19124. Features team building activities, academic enrichment, and free healthy breakfast, lunch, and PM snack. The summer camp program is Monday through Thursday from 9:00 am - 3:00 pm at the J. Hampton Moore Elementary School - Primary Education Center 6900 Summerdale Avenue (Entrance on Tyson Ave & Algon Ave ) Philadelphia, PA 19111
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Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Please Select
5
6
7
8
9
10
11
12
Gender
*
Please Select
Female
Male
Does your student have an IEP?
*
Yes
No
I am not sure
Please Explain
Does your student have any allergies?
*
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Parent / Guardian's Name
*
First Name
Last Name
Relation to Child
*
Parent / Guardian email
*
example@example.com
Phone number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code- MUST BE IN 19111, 19124, OR 19149
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What school does your child attend?
*
Do you have any other children to enroll? (If yes, please fill out under Student 2)
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Yes
No
Are you currently:
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Immigrant
Migrant
Receiving Food Stamps
Homeless
Refugee
None of the Above
Did your student qualify for the Free or Reduced Lunch Program in 2021/2022?
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Yes
No
I am not sure
What is your race/ethnicity?
*
Are there any days your child will be absent?
*
Please list any special accommodations our staff should be aware of when working with your children.
*
Please Select
IEP/Learning
Disability
Asthma
Allergies
Handicap
Other (Please Explain)
Please explain if necessary
Is your child allowed to walk home?
*
Who is allowed to pick your child up?
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
How can we best serve your children?
Please provide us with an Emergency Contact
*
Phone Number
*
Please enter a valid phone number.
What is your child[ren]'s primary language?
*
What other languages do your child[ren] speak?
*
May we safely publish photos of your child in print and/or online for OCCCDA promotional material/news articles?
*
Yes
No
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Student 2
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Gender
Male
Female
Age
Grade
School
IEP?
Yes
No
I am not sure
If yes, please explain
Does your student have any allergies?
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Student 3
First Name
Last Name
Gender
Male
Female
Birthday
-
Month
-
Day
Year
Date
Age
Grade
School
Does your student have an IEP?
Yes
No
I am not sure
If yes, please explain
Does your student have any allergies?
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I agree to the following statement
*
Please Select
Yes
No
To serve as many children as consistently as possible, priority will be given to students anticipating nearly perfect full-day attendance this summer. After 3 missed days (except in extenuating circumstances), the child’s spot may be offered to a child on the waiting list. Parents must notify Darian Regusters, our Program Coordinator at 267-625-2077. Please text or call in the event of an absence. We expect students to have regular summer camp attendance for the 6 weeks. Selection Process: We do not discriminate on the basis of race, ethnicity, gender, nor religion. Applications for new or returning campers will be accepted May 16th - June 23rd. Spots will be filled by age group. We will confirm acceptance on June 14th and pending all required paperwork is completed.
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Please agree to each statement, then sign the box below:
I understand that my student will wear a mask and have their temperature taken daily.
*
Please Select
Yes
No
I agree that neither OCCCDA (nor their board) can be held responsible for any lost or stolen items, nor for injuries.
*
Please Select
Yes
No
I give permission for OCCCDA and OCMC to: Obtain emergency care & minor First Aid and Transport by Bus/Van or walking
*
Please Select
Yes
No
Signature
*
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“Funded in full or in part with a grant from the Pennsylvania Dept of Education, Nita M. Lowey 21st Century Community Learning Centers (21st CCLC) program”
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