YPIC Summer Success Camp 2026 Registration
Welcome to Youth Positive Impact Coaching Summer Success Camp 2026!This all-inclusive program includes meals, field trips, mentoring, and skill-building experiences for youth. 💵 Cost: $125 per week 📞 (469) 552-5064 📧 Summercamp@y-pic.org
SECTION 1: Camper Info
Child's Full Name (Short Answer)
Age (Short Answer)
Date of Birth (Date)
 -
Month
 -
Day
Year
Date
Gender (Multiple Choice: Male / Female / Prefer not to say / Other)
Male
Female
Prefer not to say
Other
School Name (Short Answer)
SECTION 2: Parent/Guardian Info
Parent/Guardian Full Name (Short Answer)
Phone Number (Short Answer)
Format: (000) 000-0000.
Email Address (Short Answer)
example@example.com
Home Address (Paragraph)
SECTION 3: Emergency Info
Emergency Contact Name (Short Answer)
Emergency Phone Number (Short Answer)
Format: (000) 000-0000.
SECTION 4: Health Info
Does your child have any allergies? (Multiple Choice: Yes / No)
Yes
No
If yes, please explain (Paragraph)
Medical Conditions (Paragraph)
Does your child require medication during camp? (Yes / No)
Yes
No
If yes, explain (Paragraph)
Doctor's Name (Short Answer)
SECTION 5: Camp Selection
Weeks Attending (Checkboxes)
June 8 - June 12
June 15 - June 19
June 22 - June 26
July 6 - July 10
July 13 - July 17
July 20 - July 24
Age Group (Multiple Choice)
Ages 5-8
Ages 9-13
Ages 14-18 (Future Bosses / Barber Program - Tru Elevation)
SECTION 6: Permissions
(Checkboxes - Required)
*
I give permission for my child to attend field trips
I give permission for photos/videos to be used for program promotion
I understand there are no refunds after the camp week begins
SECTION 7: Payment
Payment Method (Multiple Choice)
Cash
Zelle
CashApp
*
I agree to pay $125 per week selected
SECTION 8: Referral & Program Status
Are you currently enrolled in YPIC services? (Multiple Choice - Required)
*
Yes
No
If yes, who is your assigned QMHP/Therapist? (Short Answer)
How did you hear about us? (Multiple Choice)
School
Social Media
Friend/Family
Church
Event/Community Outreach
YPIC Staff
Other
If referred by a person, please list their name (Short Answer)
SECTION 9: Signature
Parent/Guardian Signature (Short Answer)
"Thank you for registering for YPIC Summer Success Camp! A team member will contact you within 24-48 hours to confirm your child's spot."
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