2022 Kiwanis Club of Montgomery Camp Adventure
Please complete the form below if you want your child(ren) attend this year's camp from July 11 - August 4, 2022.
Parent/Guardian's Name:
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First Name
Last Name
Suffix (Jr, Sr, II)
Parent/Guardian's Contact Number:
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Please enter a valid phone number.
Parent/Guardian's Email:
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example@example.com
How many of your children do you want to sign-up for one-on-one tutoring on-line?
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Child's Information
Please be reminded that all children receiving virtual tutoring must be signed up for New Beginnings' tutorial services.
Child #1 Name:
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First Name
Last Name
Child #1 Gender:
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Boy
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Child #1 Birthdate:
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Month
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Please enter your child's birthdate.
Child #1 Grade:
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Child #1 School's Name:
Which subject does Child #1 need help with?
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Mathematics
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Child #1 Comments:
Child's #2 Name:
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First Name
Last Name
Child #2 Gender:
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Boy
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Child #2 Grade:
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4th Grade
5th Grade
6th Grade
7th Grade
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Child #2 School's Name:
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Child #2 Comments:
Which subject does Child #2 need help with?
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Mathematics
Reading & Language Arts
Science
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Child #2 Comments:
Child #3 Name:
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First Name
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Child #3 Birthdate:
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Day
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Please enter your Child #2 birthdate.
Child #3 Gender:
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Boy
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Child #3 Grade:
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1st Grade
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Child #3 School's Name:
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Which subject does Child #3 need help with?
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Mathematics
Reading & Language Arts
Science
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Child #3 Comments:
Child #4 Name:
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First Name
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Child #4 Gender:
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Boy
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Child #4 Birthdate:
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Please enter your child's birthdate.
Child #4 Grade:
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Kindergarten
1st Grade
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5th Grade
6th Grade
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8th Grade
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10th Grade
11th Grade
12th Grade
Child #4 School's Name:
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Which subject does Child #4 need help with?
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Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #4 Comments:
Child #5 Name:
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First Name
Last Name
Child #5 Gender:
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Boy
Girl
Child #5 Birthdate:
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Month
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Child #5 Grade:
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12th Grade
Child #5 School's Name:
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Which subject does Child #5 need help with?
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Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #5 Comments:
Child #6 Name:
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First Name
Last Name
Child #6 Gender:
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Boy
Girl
Child #6 Birthdate:
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Day
Year
Please let us know your child's birthdate.
Child #6 Grade:
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Kindergarten
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6th Grade
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9th Grade
10th Grade
11th Grade
12th Grade
Child #6 School's Name:
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Which subject does Child #6 need help with?
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Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #6 Comments:
Child #7 Name:
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First Name
Last Name
Child #7 Gender:
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Boy
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Child #7 Birthdate:
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Please let me know your child's birthdate.
Child #7 Grade:
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6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #7 School's Name:
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Which subject does Child #7 need help with?
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Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #7 Comments:
Child #8 Name:
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First Name
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Child #8 Gender:
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Boy
Girl
Child #8 Birthdate:
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Day
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Please let us know your child's birthdate.
Child #8 Grade:
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Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #8 School's Name:
*
Which subject does Child #8 need help with?
*
Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #8 Comments:
Child #9 Name:
*
First Name
Last Name
Child #9 Gender:
*
Boy
Girl
Child #9 Birthdate:
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Month
/
Day
Year
Please let us know your child's birthdate.
Child #9 Grade:
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Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #9 School's Name:
*
Which subject does Child #9 need help with?
*
Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #9 Comments:
Child #10 Name:
*
First Name
Last Name
Child #10 Gender:
*
Boy
Girl
Child #10 Birthdate:
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Month
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Day
Year
Please let us know your child's birthdate.
Child #10 Grade:
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Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Child #10 School's Name:
*
Which subject does Child #10 need help with?
*
Mathematics
Reading & Language Arts
Science
Social Studies
Other
Child #10 Comments:
Acknowledgement
Please read the following statement and click on the box provided if you agree with the terms:
*
I hereby give consent for my child(ren) to enroll/participate in New Beginnings Educational Center (New Beginnings) Virtual Tutoring and Mentoring Program (Program). I understand as part of this Program, my child(ren) will be tutored by an adult volunteer.
I hereby give permission for my child(ren)'s photo, video, sound recording, creative works and name to be used in and for promotion of New Beginnings' services and programs.
I hereby grant permission for my child(ren) to receive any medical attention deemed necessary by New Beginnings' staff, their partners and/or volunteers for injuries or sickness that occur during Program sponsored activities. I will be responsible for any and all medical costs. I will not hold New Beginnings' staff, partners or volunteers liable for any injury or damage received by my child(ren) while transported or while engaging in Program sponsored activities.
I hereby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time
Parent/Guardian's Signature:
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