Summer Camp Enrollment Form

Summer Reading Program

Prevent Summer Reading Loss
CHILD INFORMATION:
Child Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Current Reading Level
Current School & District*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Photo/Video/Display

Release Authorization
Do you consent to authorize Building Beyond the Walls Standard Photo/Video/Display?*
Should be Empty:

Summer Reading Program