2026 LL+P Registration Form

Lunch, Learn and Play Summer Camp Registration 2026:

July 6th- August 7th 9:00 am-2:30 pm
Please note that registrations are processed on a "first-come, first-served" basis. If there's availability in your child's age group, they'll be added to our roster. If the age group is full, they'll be placed on our waitlist.

Please keep an eye on your email for continued updates on registration status and program details! Your child is not confimed until an email is sent directly from a member of our team.

*There will be no camp on July 16th and 17th!*
Camper Information
Camper's Name*

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

MonthDayYear
Asian or Pacific IslanderBlack or African AmercianHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialA race/ ethnicity not listed
Camper's Primary Spoken Language *
Entering Grade Fall 2027*
School District Attending Fall 2027*
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.Format: (000) 000-0000.
Email*
example@example.com
Parent 1/Guardian 1 Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Parent 2/Guardian 2 Alternate Phone Number
Alternate Work or Home Number Format: (000) 000-0000.
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.Format: (000) 000-0000.
Other Person(s) Authorized to Pick up Child:
Additional Person Authorized to Pick up Child

Additional Person 1 authorized to pick up childAdditional Person 2 authorized to pick up child
My child will be dropped off at the Courthouse, no earlier than 9:00am.My child will be walking to the Courthouse, no earlier than 9:00am.
My child will be picked up the Courthouse no later than 2:30pmMy child will walk home. This means my child will need to leave no later than 2:30 pm
This year we are offering swim lessons, in partnership with the Hebron Camp, Monday- Thursday afternoons. Campers will leave the Courthouse Campus around 1:30p and return around 3:45p. All campers must be picked up at the Courthouse Campus at 3:45p. *Limited spots are available!*
Yes, please add me to the info listNo, thank you
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.
YesYes, but only for LLPYes, but unavailable for LLP hoursMaybe- 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
SNAP benefitsTANFMedicaidSSS RecipientHEAPSafety NetOtherNone
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 and Play Summer Camp Registration 2026:

Please note that registrations are processed on a "first-come, first-served" basis. If there's availability in your child's age group, they'll be added to our roster. If the age group is full, they'll be placed on our waitlist.

Please keep an eye on your email for continued updates on registration status and program details! Your child is not confimed until an email is sent directly from a member of our team.