The 4 Lessons Superhero Enrichment Camp Registration Form

The 4 Lessons Superhero Enrichment Program

Presented by People United Foundation Hosted at Pleasant Hill CME Church 1201 Pleasant Circle, Conyers, GA 30012 Thank you for your interest in The 4 Lessons Superhero Enrichment Program, a youth and family summer learning experience based on The 4 Lessons: A Super Hero Lies in You. In-person enrichment sessions are available on Mondays and Wednesdays from 10:00 AM to 2:00 PM during the Pleasant Hill CME Church feeding program, June 15 through July 15. Snack and lunch are provided through the church feeding ministry on feeding program days. Families may also express interest in additional small-group sessions and hybrid online learning activities between in-person sessions. Preferred ages: Elementary youth, ages 6–11. Cost: Free / Donations Welcome. Contact: Lyndon Greene | 575-208-4563 | info@thepuf.org
Parent / Guardian Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Youth Participant Information
Child’s Full Name

First NameLast Name
Child’s Age
Child’s Grade Level
Child’s School
Allergies, Medical Conditions, Dietary Restrictions, Learning Needs, Behavioral Needs, or Special Accommodations
Current Medication Staff Should Be Aware Of
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attendance and Meals
Which session(s) would your child like to attend?
Will your child participate in snack and/or lunch provided through the Pleasant Hill CME Church feeding ministry on church program days?
Will a parent, caregiver, or adult family member participate in selected family enrichment conversations?
Pickup Authorization
Who is authorized to pick up your child?
Is there anyone who is not authorized to pick up your child?
Permissions and Acknowledgments
I give permission for my child to participate in The 4 Lessons Superhero Enrichment Program activities, including reading, storytelling, creative projects, movement, leadership exercises, group discussion, reflection, family enrichment activities, and optional hybrid online learning activities.
Meal Acknowledgment
Liability Acknowledgment
Emergency Medical Authorization
I give permission for my child to be photographed or recorded for:
Future Program Updates
How did you hear about The 4 Lessons Superhero Enrichment Program?
If other, please specify.
Signature
Parent/Guardian Electronic Signature
Date

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Date
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The 4 Lessons Superhero Enrichment Program

Parent / Guardian Information

Youth Participant Information

Emergency Contact

Attendance and Meals

Pickup Authorization

Permissions and Acknowledgments

Signature