Clone of Camp CARE Summer 2025 Application

UA House at Fayette Camp C.A.R.E. Summer Program

2025 Summer Camp Application
Program Registration Form
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
School Name*
Student ID Number*
If you don't know it put 0000
Does your child have an IEP or 504 Plan? *
If YES, we ask that you provide a copy of the plan(s) to CARE staff.
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload report card*

Browse Files
Application will be rejected without proper documentation Cancelof
Do you reside in PVG? (Pleasant View Gardens)*

YesNo
Grade Next School Year*
We except 1st -8th grade
Parent/Guardian Information
Please make sure all contact info Valid.
Parent 1*

First NameLast Name
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Home Number

Area CodePhone Number
Parent 2*

First NameLast Name
E-mail*
Please make sure email is correct
Cell Number*

Area CodePhone Number
Please select all that apply.*

Black/AfricanHispanic/LatinoBi-RacialAsianWhite/CaucasianOther
Work Number

Area CodePhone Number
Home Number

Area CodePhone Number
E-mail*
example@example.com
Child's Dismissal Plan
How will your child be leaving program at dismissal?*

Pick-upWalk HomePublic Transportation
Pick-Up Name 1*

First NameLast Name
Pick-up Phone Number*

Area CodePhone Number
Pick-Up Name 2*

First NameLast Name
Pick-up Phone Number*

Area CodePhone Number
Pick-up Policy*

I understand that a photo copy for pick-up person(s) must be submitted with application at the time of submission. I understand that LCF staff may request proof of identity at time of pick-up.
Drop-Off /Pick-Up Time Policy*

I understand that the latest my child can arrive at summer camp is 9:00 am. I understand that the earliest my child may depart summer camp is at 3:00 pm.
Late Fee Policy*

I understand that I will be charged a late fee of $25 after 3:00pm.
Family Information
Please select all that apply.*

Two Parent HouseholdSingle Parent MotherSingle Parent FatherLegal Guardian - RelativeOther Non-RelativeLegal Guardian - Non-RelativeFoster CareTANF Recipient (Food Stamps)Eligible for Free or Reduced Lunch
Inclusion Policy/Non-Discrimination Policy*

I understand that Living Classrooms Foundation (LCF) is committed to providing an environment free from unlawful discrimination of any type including discrimination based on race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected by law.
Emergency Information
Emergency Contact 1*

First NameLast Name
Relationship*
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Home Number

Area CodePhone Number
E-mail*
example@example.com
Emergency Contact 2*

First NameLast Name
Relationship*
Cell Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Home Number

Area CodePhone Number
E-mail*
example@example.com
Allergy Emergency & Medical Emergency Information
Does the child have any allergies?*

YesNo
If yes, please list all allegies.
Please list any medications associated with the allergy.
Does the child have medical condition(s) other than allergies?*

YesNo
If yes, please list the medical condition(s).
Please list any medications associated with the medical condition(s).
Child's Physician Name*

First NameLast Name
Physician's Number*

Area CodePhone Number
Immunization Information

I. For participants who reside within the United states, a US territory, or the District of Columbia:
State of Residence*
Is child exempt from any immunizations?*

YesNo
If Yes, list the exemptions
II. For participants who reside outside the United States, it's territories or the District of Columbia:
Country of Residence
Enrollment & Liability Release / Medical Information*

I am a legally competent adult who is parent or guardian of the named participant. I would like my child to participate in Living Classrooms Foundation (LCF) programming and expressly give my permission. I understand that even when every reasonable precaution is taken, incidents and accidents may occur. Therefore, in exchange for LCF allowing my child to participate, I voluntarily and intentionally hold harmless and release LCF, its directors, officers, employees and agents from all liability for loss, damage, injury, death, including any claims based on ordinary negligence, action, or inaction connected solely by LCF’s negligence. I also agree to indemnify LCF for claims made by or for the participant or claims arising from any relationship with the participant or the participant’s estate. I have read this form and grant permission for my child to participate in all activities provided by LCF’s C.A.R.E. afterschool/summer camp program.
Authorization for Emergency Treatment*

If my child should become ill or injured during LCF’s C.A.R.E. program activities, I understand that LCF’s C.A.R.E. program will: 1) contact me immediately 2) contact the person(s) designated in case I cannot be reached. Should LCF be unable to reach me or the person(s) designated, LCF is authorized to contact my physician or arrange for immediate medical treatment to ensure the health and safety of my child, including the administration of medications or injections provided by me for such purpose. I accept responsibility for payment of medical services rendered.
Minor Media Release (under age 18)*

In consideration of my child’s engagement as a subject and other consideration herein acknowledged as already received, and without further consideration or compensation now or in the future, I hereby give Living Classrooms Foundation and its legal representatives and assigns the right and permission to publish images of my child and statements by my child as captured through photography, videography, audio recording, and written communication while participating in Living Classrooms and affiliate programs and as a program graduate. I further authorize modification of these images and statements for correctness and artistic effect so long as the changes do not result in intentional and harmful misrepresentation. Without time constraint and without further notification, these images and statements may be used—with or without appropriate identification of my child by name, school affiliation, age, and/or affiliation(s) with Living Classrooms Foundation—in any Living Classrooms publication or communication (e.g. web pages, multimedia presentations, television commercials, promotional literature, fundraising collateral materials, advertising, and participant recruitment campaigns) whether print, electronic, or broadcast.
Adult Media Release

In consideration of my engagement as a subject and other consideration herein acknowledged as already received, and without further consideration or compensation now or in the future, I hereby give Living Classrooms Foundation and its legal representatives and assigns the right and permission to publish images of me and statements by me as captured through photography, videography, audio recording, and written communication while participating in Living Classrooms and affiliate programming and as a program graduate. I further authorize modification of these images and statements for correctness and artistic effect so long as the changes do not result in intentional and harmful misrepresentation. Without time constraint and without further notification, these images and statements may be used—with or without appropriate identification of me by name, employer, age, and/or affiliation(s) with Living Classrooms Foundation—in any Living Classrooms publication or communication (e.g. web pages, multimedia presentations, television commercials, promotional literature, fundraising collateral materials, advertising, and participant recruitment campaigns) whether print, electronic, or broadcast.
Confirmation

BY SUBMITTNG AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Mandatory!

Please check your email!

Orientation will be on June 12, 2025 @ 6:00p.m. @1100 E. Fayette St.

If you have a camper that has been the to UA House Summer Camp before you do not have to attend Orientation.

Only for new campers
Should be Empty:

UA House at Fayette Camp C.A.R.E. Summer Program