Youth Mentoring Registration Form

LearnWorks Reading & Math Enrichment
Community Care Development Network (CCDN) exists to develop, transform, andrestore life to families, adults, teens, and the community to be committed, unified, and mature. We are headquartered in an area of Birmingham where individuals and families are fighting uphill battles to survive on a daily basis and often cannot see past their daily challenges to improve their long-term family situations including education, employment, and vocational training, child care, and healthy relationships. We help fulfill basic daily needs, build relationships as we meet those needs, and then help address underlying circumstances.

What is LearnWorks?
- LearnWorks is a Reading & Math Enrichment Camp Program to strengthen reading and math skills?
Who is LearnWorks for?
- LearnWorks is for youth 5th grade to 12th grade who are at least 1 grade level behind in reading and math?
What all is covered under LearnWorks?
- Reading Basics-Phonics, Sequence, Reading Comprehension, Reading Flow, and Writing
- Math Basics-Addition, Subtraction, Multiplication, Division, Counting Money, Time, Fractions, and Decimals
When and where is the camp held?
- Camp is held the second week in July through the fourth week in July, Monday-Wednesday, 8:00 am-12:00 pm
Is there a cost for the camp?
- No, LearnWorks is absolutely free?
Will I need to purchase supplies for camp?
- No, CCDN provides all of the supplies needed.
Is transportation provided?
- No, unfortunately this year we do not have transportation.
Will meals be provided?
- Yes, we will provide breakfast, lunch, and a snack during camp.
2022 LearnWorks Schedule
- Week 1-July 11-13 8:00 AM-12:00 PM
- Week 2-July 18-20 8:00 AM-12:00 PM
- Week 3-July 25-27 8:00 AM-12:00 PM
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Home Number
What area(s) does your child need assistance in? (Check All that Apply)

Reading Phonics Reading Sequence Reading Comprehension Reading Flow Writing Math-Addition & Subtraction Math-Multiplication & Division Math-Fractions & Decimals Math Time & Money
Questions or Additional Comments
Guardianship
Parent or Legal Guardian Information

First Name Last Name
Cell Phone (Parent or Legal Guardian)
Home Number (Parent or Legal Guardian

Emergency Persons/Emergency Contacts/Medical Information
PICK UP: Person with permission to pick up youth other than parents:

First Name Last Name
Relationship
Phone Number
EMERGENCY CONTACT

First Name Last Name
Relationship
Phone Number
In case of emergency do we have permission to obtain medical attention for you/youth.

Yes No
NOTE: Please be advised that CCDN will require a copy of the insurance card on file for emergency purposes.
Are there any allergies including food allergies or medical conditions CCDN need to be aware of?

Yes No
Please explain here:

LearnWorks Reading & Math Enrichment

Education and Behavioral Analysis

Emergency Persons/Emergency Contacts/Medical Information

Parent Consent and Certification