Harvest of Gold Summer Program Application Form 2026
2026
Student Information
Name
*
First Name
Last Name
Grade
*
School Last Attended
*
Gender
Please Select
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are there any learning needs, accommodations, or school supports we should know about to help your child have the best experience? Optional: This may include an IEP, 504 Plan, tutoring supports, behavior supports, sensory needs, reading/math concerns, or strategies that work well for your child. This information is optional and will only be used to help us support your child during programming. It will not affect registration or participation.
Approved Pick-Up/Drop-Off Individuals
Please understand that the individuals that are listed will have the authority to pick up your child(ren).
Name
*
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Emergency Information
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Format: (000) 000-0000.
Health Information
Family Doctor
First Name
Last Name
Clinic
Phone Number
Format: (000) 000-0000.
Please let us know if this child have any allergies
*
List medications if this child is currently taking
Can this child take part in regular physical activities?
*
Yes
No
Do you want to indicate any related information?
Summer Program Schedule
June 22nd-July 3rd. Monday & Tuesday grades Pre-K - 2. Wednesday and Thursday grades 3 - 5. Friday Pre-K - 5th Grade.
Terms and Conditions
I, the parent or guardian of the minor participant, will hold harmless Harvest of Gold, Bible Missionary Baptist Church, CCYC, Wilmington City Schools, Wilmington College volunteer student tutors, and the servants, agents, employees, trustees, directors, representatives, and volunteers from any and all injuries, damages, claims, costs, expenses, losses, attorneys fees, and/or every loss of whatsoever nature that I and/or the minor participant incurs or may incur arising out of my and or the minor participant's participation in an event or activity sponsored or supervised, and/or approved as part of the Harvest of Gold/WCS Partnership official and unofficial programs. I am solely responsible for payment of all costs resulting from the rendering of medical aid and ambulance services to myself and/or the minor participant in any event and/or activity of the Harvest of Gold/WCS Partnership Reading Program. Neither Bible Missionary Baptist Church nor Harvest of Gold or Wilmington City Schools carries any medical and/or liability insurance to cover participants. Participation in all activities is voluntary. This release of liability, assumption of risk and medical authorization shall be binding upon me and/or the minor participant, my/our heirs, administrators, executors, personal representatives, and assigns. I have read the above release of liability, assumption of risk, and medical authorization and understand the provisions thereof and I and/or the minor participant am/is voluntarily participating in the Harvest of Gold/WCS Partnership reading program subject to the term and conditions thereof. Select yes if you have read and agreed to the terms.
*
Please Select
yes
no
By signing this form, I also give Harvest of Gold of Wilmington, Inc. permission to use pictures taken of my son/daughter. The pictures could be used on social media, flyers, brochures, or newsletters for advertisement and grant writing.
*
I have read and understand the Parent Handbook.
Please Select
yes
no
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
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