Camp ACTIVATE Application 2026

Student Name*

First NameLast Name

Gender*

FemaleMalePrefer not to respond

Date of Birth*

Date

Grade completed as of June 2026 (Camp Activate is only for students exiting 3rd, 4th, & 5th grade)*

Primary Language*

EnglishSpanishOther

Ethnicity*

Child Lives With*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School*

T-Shirt Size*

Name*

First NameLast Name

Relationship to Student*

Work Phone*

Format: (000) 000-0000.

Cell Phone*

Format: (000) 000-0000.

Email Address*

example@example.com

I hereby give permission for the participant listed above to take part in the Activate Program activities, which may include off-site events, academic assistance, continuing education, and recreational programs. Activate Summer Camp has permission to provide my child with food and water over the course of the camp day. I authorize Youth Empowerment Source to release and/or obtain information from Cecil County Public Schools

If an emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transportation to an emergency facility. I understand that I will be responsible for any transportation charges and/or medical expenses incurred. I agree that if a health condition exists now or in the future which would impact the participation of the student named above, I will notify the Activate Program Staff.

I give my consent to Youth Empowerment Source, and the Activate Staff to take the participant's photograph, video, or audio during the program, to be used for education or marketing purposes.

Name*

First NameLast Name

Signature*

Today's Date*

Date

Camp ACTIVATE Application

Parent/Guardian Information

Health/Medical Form

Transportation Form

For the safety of our students, please ensure that any individual who picks up your child has a photo I.D. with them.

Please list below anyone who is NOT allowed to pick up your child from camp: