Child's Name*

This field is mandatory

Last Name*

This field is mandatory

School Attending*

This field is mandatory

Child Phone No. *

This field is mandatory

Age*

This field is mandatory

Gender*

This field is mandatory

Ethnicity*

This field is mandatory

Participant in School Lunch Program

What are some Interests for spring or summer breaks: (Check all that apply):

Digital Learning

STEM

Sports

Creative Arts

Technology

What are some things Needed for spring or summer break: (Check all that apply):

Tutor

Mentor

Soft skills

Mental Health

Education

Other

Some Challenges you face( Check all that apply ):

Bully

Safety

Peer Pressure

Drug Influences

Depression

Other

Parent / Guardian Information

Full Name*

This field is mandatory

Street Address*

This field is mandatory

City, State, Zip Code*

This field is mandatory

Phone Number*

This field is mandatory

Email*

This field is mandatory

Ethnicity*

This field is mandatory

Income Status (Check One that Apply)

0- $10,000

$11,000- $25,000

$26,000-$50,000

$51,000 - $75,000

$ 76,000- UP

Are you willing to volunteer ?

Yes

If, So please check all that apply…

Temporary work – such as summer or holiday work?

Regular part-time work?

Regular full-time work?

Primary Emergency Contact

Contact Name*

This field is mandatory

Relationship to Contact*

This field is mandatory

Home Telephone*

This field is mandatory

Cellular Telephone*

This field is mandatory

I hereby declare and certify that information written on application is true and complete to the best of my knowledge and can be used for funding purposes. *

This field is mandatory

Parent or Guardian Signature*

This field is mandatory

Date*

This field is mandatory

* Indicates required fields

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Application for Summer Camp