Summer Camp Registration
K-5th Grade Summer Camp. Each student needs an individual application.
Participant Information
Full Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Summer Camp Start Date: (summer camp starts June 10th, 2024)
*
-
Month
-
Day
Year
Date
Current Grade
*
Please Select
Kinder
1st
2nd
3rd
4th
5th
6th
Gender
*
Please Select
M
F
Ethnicity
*
Please Select
Hispanic
Haitian
Neither
Other
Race
*
Please Select
African American
American Indian
Asian
Biracial or Multiracial
White
Other
Condition or disability lasting a year or more
*
Yes
No
If yes to previous question, Please name condition, disability or any therapies child has.
*
Is the participant a current Liberty Academy Student?
*
Yes
No
Parent/ Guardian Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Parent Signature
*
Print Form
Submit
Submit
Should be Empty: