2026 Summer Camp Registration
Youth Development Summer camp partnered with the children trust and FIU reading explorers for students going to Kindergarten though 5th Grade
Childs Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Current Grade as of Today
*
Please Select
VPK
Kinder
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Has Your Child participated in our Summer Camp before?
*
Yes
No
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Participant Infromation
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Participant Race/Ethnicity
*
Please Select
Biracial or Multicultural
Black Non Hispanic/ African American
White Non- Hispanic
Hispanic
Other
Prefer not to answer
Mark all languages your child speaks
*
English
Spanish
Creole
Other
Address and Location
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Infromation
Caregiver Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Caregiver preferred language
*
Please Select
English
Spanish
Haitian Creole
Other Demographics
To support your child's participation what areas need extra assistance?
*
Please Select
Academic and Learning supports, such as reading or understanding basic instruction
managing feelings or behaviors, such as needing extra support or structure
Chronic health condition management, such as epi, inhaler or other medications
Fine motor tasks
Gross motor tasks
Adapting activities to consider visual, speech or hearing needs
Personal service such as feeding or toileting
Using assistive devices like wheelchair or crutches
Other
No specific help need
Do any of the conditions noted make it harder for your child to do things that others of the same age can do?
*
Yes, it is harder for them
No, it is not harder for them
N/A, no conditions noted
What are the main ways in which your child communicates?
*
Please Select
Speaks and is easily understood
Speaks but is difficult to understand
Use communication devices like pictures or a board
Uses sign language
Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking
Uses sounds that are not words like laughing, crying or grunting
What, if any, help does your child receive at this time?
*
Please Select
Behavioral therapy or services
Counseling for emotional concerns
Daily medication ( not including vitamins)
Occupational Therapy
Physical Therapy
Speech/ Language therapy
None of the above are needed at this time
At least one of these services are needed but not received
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Has any of your information from last year changed?
Yes
No
Summer Camp Acknowledgement
I acknowledge that I am signing my child up for Liberty Academy’s Summer Camp program. I understand that summer camp is free of charge. I also understand that completing this sign-up form helps Liberty Academy plan for staffing, activities, meals/snacks, and supplies. By signing below, I confirm that the information provided is accurate and that my child is expected to attend summer camp.
Signature
Submit
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