Kingsley House 2022 Summer Camp Registration

Camp I Am! Summer 2023

Youth Services Department
Empowering Today's Youth to Become Tomorrow's Leaders
Camper Eligibility

Thank you for your interest in Camp I AM! We are excited about the activities planned for this summer.

Campers must be rising 3rd through 8th graders for the fall 2023 academic year (no exceptions).

The cost of this year's camp is $300 for each 4-week session per camper. The registration fee is $20 per camper.

Registration and payment deadline for Session II is Monday, July 3rd.

Please be sure to complete this application in its entirety.
Camper's Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Camper's T-shirt Size (children's sized)*
Grade in the fall 2023 *
School in Fall 2023*
Parent or Legal Guardian Information
Select the Clover program your family is already enrolled with, if any:

Early Head Start/Head StartResident Engagement (Columbia Parc/Faubourg Lafitte)Clover ConnectionsNo Clover program
Parent/Legal Guardian 1*

First NameLast Name
Parent/Legal Guardian's Email*

Confirmation Emailexample@example.com
Relation to Camper*

FatherMotherLegal Guardian
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Parent /Legal Guardian 2
Relation to Camper

FatherMotherLegal Guardian
Work Phone Number 2
Please enter a valid phone number.
Cell Phone Number 2
Please enter a valid phone number.
Emergency Contact(s) Release Information

List anyone, other than Parents/Legal Guardians named above, to whom your camper can be released. These individuals will be contacted in case of an emergency and/or allowed to sign campers out.
Emergency Contact Name 1

First NameLast Name
Phone Number
Emergency Contact Name 2

First NameLast Name
Phone Number
Emergency Contact Name 3

First NameLast Name
Phone Number
Emergency Contact Name 4

First NameLast Name
Phone Number
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. Please bring all medication in its ORIGINAL CONTAINER and with its pharmacy label. No exceptions. All prescriptions must be in the camper's name and state the correct dosage.
List all medications, both prescribed and over the counter. All medications will be handled by the health officer except rescue inhalers. and must be submitted in the original containers.
All of the below fields must be completed. If nothing applies, please enter NA.
List any specific allergies (ex: bees, peanuts, grass).*
Any dietary needs we should be aware of (eggs, dairy)?*
Are there any medical conditions that may affect your camper's participation?*
Any medical condition(s) that would require special attention or medication while at camp (asthma, diabetes, seizures)?*
List any past medical treatments that would be helpful for us to know.*
Consents

Attendance, Medical, Dismissal/Release and Media.
Check all that apply.*

I certify that my child has my permission to attend the Clover camp and participate in all activities unless otherwise stipulated in this form.In case of a medical emergency or general medical care, I give consent to Clover to administer medicine for the above named camper and to transport in case of a medical emergency.I understand that the above named camper will only be released to the names listed above and that I am the only person who can amend the names.I grant Clover permission to use my camper's picture, testimony, and video in any promotional material(web, print, or media).I give permission to Clover to text me for purposes related to summer camp 2023 and/or my child/ren.I understand I am required to pay $300 per camper, per session payable prior to the start of each session to maintain my child/ren's enrollment.
Signature confirming you are the parent or legal guardian of the above named camper and are over the age of 18.*

Clear
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Camp I Am! Summer 2023

Empowering Today's Youth to Become Tomorrow's Leaders

Camper's Information

Parent or Legal Guardian Information

Emergency Contact(s) Release Information

Health Information

Consents