Clone of 2025 LL&P Detailed Registration Form

Lunch, Learn + Play Winter Camp 2025:

Monday, Dec. 22nd 9:30am-1:30 pm
Please note that registrations are processed on a "first-come, first-served" basis. If the group is full, your camper will be placed on our waitlist.

*Winter Camp is limited to 20 participants!*

Please keep an eye on your email for updates on registration status and program details!

*You must recieve a registration confirmation email from Historic Salem Courthouse to ensure your camper is enrolled! *
Camper Information
Camper's Name*

Camper's First NameCamper's Last Name
Birth Date*

MonthDayYear
Ethnicity*

Asian or Pacific IslanderBlack or African AmercianHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialA race/ ethnicity not listed
Current Grade (winter camp is for students in K-3rd)*
School District Residency*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent 1/Guardian 1 Name *

Parent 1/ Guardian 1 First NameParent 1/Guardian 1 Last Name
Parent 1/Guardian 1 Phone Number*
Please enter a valid phone number.
Parent 1/Guardian 1 Alternate Phone Number
Please enter a valid phone number.
Parent 2/Guardian 2 Name

Parent 2/ Guardian 2 First NameParent 2/Guardian 2 Last Name
Parent 2/Guardian 2 Phone Number
Please enter a valid phone number.
Parent 2/Guardian 2 Alternate Phone Number
Alternate Work or Home Number
Emergency Contact Information (person to contact if both Parents/Guardians cannot be reached)
Emergency Contact *

Emergency Contact First NameEmergency Contact Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Arrival Plans*

My child will be dropped off at the Courthouse, no earlier than 9:30am.My child will be walking to the Courthouse, no earlier than 9:30am.
Dismissal Plans*

My child will be picked up the Courthouse no later than 1:30pmMy child will walk home. This means my child will need to leave no later than 1:30 pm
Photo Consent*

I give permission for my child's photograph to be used in publicity for Lunch, Learn and Play, including newspapers, websites, FB and Instagram. This means your child will be included in group shots.I do NOT give permission for my child's photograph to be used in publicity for Lunch, Learn and Play, including newspapers, websites, FB and Instagram. This means your child will NOT be included in any group shots.
We strongly encourage parent/guardian participation. As the parent or guardian, I am willing to volunteer for an event/activity at the Historic Salem Courthouse Community Center or LLP during the summer.

YesYes, but only for LLPMaybe- please tell me more!No
Best E-mail to Send Notifications about Program Details (please ensure you're checking your "junk folder" from time to time!*
example@example.com
Please indicate if your child receives any of these benefits below. Please note, all of this information is confidential. We receive grants for LL&P and this data is important to illustrate when we are applying for grants.*

SNAP benefitsTANFMedicaidSSS RecipientHEAPSafety NetOtherNone
Does Child have Insurance*

YesNo
If yes, indicate carrier or plan group name and number *
Insurance Carrier and Insurance Plan Number
Insurance Card Information (if this is not a picture of your active insurance card, the registration will be deleted after you submit, and will not be processed. ) *

Cancelof
Copy of Latest Immunization Record ( if this is not a valid immunization record, the registration will be deleted after you submit, and will not be processed- please do not ask the school nurse*

Cancelof
Physician's Name*

Physician's Name Dr. Phone Number
Dentist's Name*

Dentist NameDr. Phone Number
Does the camper have any ALLERGIES, CHRONIC ILLNESS, or MEDICAL CONDITIONS? If yes, please describe below. If not applicable, simply write N/A in the space. Please note, we are NOT a peanut/gluten free environment and offer no special diets. *
Is the camper prescribed an inhaler or an epi-pen? If yes, please be aware that he/she will need to carry it in their back pack and be able to administer themselves with supervision. We are not allowed to administer medications other than basic first aid. If not applicable, simply write N/A in the space.*
So we may better serve your child, please tell us any information that we may need to know about your child such as behavioral issues or any concerns you have. This is also an area to indicate camp activities your child can not participate in. If not applicable, simply write N/A in the space.*
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any activities prepared by the Historic Salem Courthouse's Lunch, Learn and Play program.

In case of injury or emergency to said child, I give Lunch, Learn and Play staff permission to seek medical treatment for my child.
Medical Treatment Authorization

This health history is correct and complete. The person described in this form has permission to engage in all camp activities except as noted within. I hereby give permission to Lunch, Learn and Play, at the Historic Salem Courthouse, to provide, seek, and consent to routine health care and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests, and treatment, and/or hospitalization. I also permit the camp to arrange related transportation. I agree to release any records necessary for treatment, referral, billing, or insurance purposes.

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Lunch, Learn and Play to secure and administer treatment, including hospitalization, for the person named above.
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.
Should be Empty:

Lunch, Learn + Play Winter Camp 2025:

Please note that registrations are processed on a "first-come, first-served" basis. If the group is full, your camper will be placed on our waitlist.

*Winter Camp is limited to 20 participants!*

Please keep an eye on your email for updates on registration status and program details!

Winter Camp is limited to 20 participants!