GoodLife Youth Summer Experience Waiting List

City of Refuge GoodLife Foundation Summer Experience
Our Summer Camp is currently full. However, you may join our waiting list, and we will contact you if a spot becomes available.
Child Information
Child Name

First NameLast Name
Age
Date of Birth
T-Shirt Size (be specific)
Gender

MaleFemale
Parent / Guardian Information
Parent Name

First NameLast Name
Email
example@example.com
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Household and Income

Using the chart below, determine if the household income is at or below 200% of the 2024/2025 Federal Poverty Level limits. Select the applicable household family size and monthly income that matches the income status for the applicant family.
Number of household members
Is the family's total income at or below 200% of the Federal Poverty Level based on household size?

YesNo
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Child
Medical Information
Does your child have allergies? If yes, please list:
Does your child have any current medical conditions? If yes, please list:
Does your child take any medications? If yes, please list and explain its purpose
Comments/concerns (Note: Please bring all current medication(s) with you on first day)
Registration

$49.95 Per Week Per Camper

Click/tap here to make payment of $49.00

Save $50.60 by paying $349.00 Per Camper for all 8 weeks

Click/tap here to make payment of $349.00
Acknowledgement, Authorization, and Waivers
My child has my authorization to engage in the activities of the GoodLife Youth Summer Experience.

I allow taking photographs of my child that can be used for GoodLife Youth’s portfolio or advertising.

I authorize GoodLife Youth Summer Experience staff to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if they are unable to contact the parent/guardian or the emergency contact person. I allow them to apply first aid, medical or surgical diagnosis and treatment as necessary.

I release GoodLife Youth Summer Experience and any of its coaches, staff, and managers for any responsibility in case of accident, illness, or injury during my child’s enrollment.

I authorize GoodLife Youth Summer Experience to transport my child by bus or van, driven by an individual authorized by GoodLife Youth Summer Experience. This authorization includes field trips and emergency transport. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer.

I confirm that all information given in this form is true, complete, and accurate.

I have read this entire authorization form and waivers, I fully understand its terms and conditions, and I agree to be legally bound by its terms.
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City of Refuge GoodLife Foundation Summer Experience

Child Information

Parent / Guardian Information

Emergency Contact Information

Medical Information

Acknowledgement, Authorization, and Waivers