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?*

I consentI do not consent
Should be Empty:

Summer Reading Program