Summer Camp Registration ages 11-13

Summer Camp Registration ages 11-13

Elementary enrollment is at capacity
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade COMPLETED in 2024-2025 School Year*

2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade
Sibling's Name ATTENDING Camp (optional)

First NameLast Name
Grade Completed in 2024-2025 School Year (optional)

2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
E-mail*
Confirm E-mail*
example@example.com
What COUNTY does your child attend school in?*
Emergency Information Other than the name listed above
Emergency Contact's Name*

First NameLast Name
Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Did you "Refer a Friend"? Please tell us the registered camper you invited who hasn't been to our Summer Reading Camp before!
If you are requesting therapy for your child, please list concerns that you would like addressed:
If there are sensitive issues that we should know about your child as it involves sexual assault, or domestic violence, please indicate that here, as there are special services that can be provided for your child. Sponsorship is also available so that camp is free for your child. All information is confidential. Please indicate your child's special circumstance if this applies.
If there are any diagnosis that your child has, please indicate that here:
If there are any medications that your child is on that needs to be administered during the day, please list the medications:
Education Accommodations: Does your child have an IEP, 504 Plan, or Behavioral Plan?
What school does your child attend?*
If there are transportation issues, please explain here:
If your child has allergies, please indicate those allergies here:*
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by (insert tutoring name here) during the selected camp. (insert tutoring name here) is not responsible for increased grades in school. However, we do guarantee providing each student with developmentally appropriate tasks, strategic lessons, and researched based content to improve their reading and/or math performance.
AgreeI do not agree
Media Disclosure (insert tutoring name here) may periodically photograph students participating and working during camp. These photographs may be used in a variety of ways; Public relations and marketing purposes: images printed on brochures, posters, and newsletters, or on (insert tutoring name here) Website, Facebook Page, and/or other art, education, or news related publications. Please indicate whether you will allow publication of photographs taken of your child/children and their literacy work during classes. Names will not be included in photographs or posted on social media. We appreciate your support and would love the chance to share pictures of all of the fun being had at our Summer Reading Camp. You can also follow us on Facebook to capture all of the pictures yourself!
AgreeI do not agree
Camp Fees are $50 per session
Confirmation BY ACKNOWLEDGING 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.
Signature

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Session 1 for 1 child July 7-17This is for a 2 week summer session.
$50.00

Session 2 for 1 child August 4-14This is for a 2 week summer session.
$50.00 Quantity

Total

$0.00
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