2025 CCFL Camp Application Form

1
Does your student live in the Lakeview Community or attend Faith Memorial MBC?* This field is required.
Yes
No
2
Students Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Upcoming Grade Level in the 2025-2026 Academic Year* This field is required.
Please Select
Please Select
1st
2nd
3rd
4th
5th
6th
6
2025-2026 School Name* This field is required.
7
Gender* This field is required.
Please Select
Please Select
Male
Female
N/A
8
Are you of Hispanic, Latino, or Spanish origin?* This field is required.
No
Yes
9
Regardless of how you answered the last question, please indicate how your child identifies their race. (Select as many as apply.)* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino descent (Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture)
White
Other
10
Student has an Individual Educational Plan?* This field is required.
Yes
No
11
Would your child like to participate in Bike Camp?
Yes
No
Need more details
12
Parent / Guardian 1 * This field is required.
First Name
Last Name
13
Relationship* This field is required.
14
Phone Number* This field is required.
Area Code
Phone Number
15
Email* This field is required.
example@example.com
16
What is your age?* This field is required.
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
Age 65 or older
17
What is the highest degree or level of education you have completed?* This field is required.
Less than high school
High School graduate (includes equivalency)
Some College, no degree
Associate's degree
Bachelor's degree
PH.D.
Graduate or professional degree
18
Parent / Guardian 2
First Name
Last Name
19
Relationship
20
Phone Number
Area Code
Phone Number
21
Email
example@example.com
22
What is your age?
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 64 years
Age 65 or older
23
What is the highest degree or level of education you have completed?
Less than high school
High School graduate (includes equivalency)
Some College, no degree
Associate's degree
Bachelor's degree
PH.D.
Graduate or professional degree
24
What was your total combined household income before taxes the past 12 months?* This field is required.
Less than $25,000
$25,000 to $34,000
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,000
$150,000 to $199,999
$200,000 or more
25
Please list in order of whom to contact first* This field is required.
26
Family Doctor
First Name
Last Name
27
Clinic
28
Phone Number
Area Code
Phone Number
29
Please let us know if this child have any allergies* This field is required.
30
List medications if this child is currently taking* This field is required.
31
Has this child had any serious illnesses or operations?* This field is required.
No
Yes
32
If yes, please describe
33
Can this child take part in regular physical activities without limitations?* This field is required.
Yes
No
34
Do you want to indicate any related information?
35
Date of Registration
Date
Month
Day
Year
36
For Summer 2025 (Please select one)* This field is required.
My family has the ability and resources to pay for a 6-week summer camp program and/or summer childcare for our child/children
My family has the ability and resources to attend another free summer camp and/or free childcare option but chose to have our child/children attend Charlotte Champions for Life
Charlotte Champions for Life was the ONLY summer camp and childcare option for my family
37
Do you believe your child/children will be set up for success in the upcoming academic year by attending the CCFL summer camp?* This field is required.
Yes
No
38
Do you believe that throughout the duration of the CCFL 6-week program that you will become better equipped, as a parent, for the upcoming academic year?* This field is required.
Yes
No
39
Are you interested in having your child/children attend Charlotte Champions for Life Summer Camp next summer (2025)?* This field is required.
Yes
No
Unsure
40
Are you interested in registering your child/children in the POP's Passion After-school Program in the upcoming academic year (2024-2025)?* This field is required.
Yes
No
41
How likely are you to recommend the Charlotte Champions for Life summer camp program to * This field is required.
1
2
3
4
5
Will Not Recommend
Will Likely Recommend
42
Are their any comments, suggestions, or expectations that you have of the CCFL Summer Camp Program that you would like to add?
Should be Empty: