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Middle School Summer Enrichment Camp

Events

Walkersville United Methodist Church, 20 Main St., Walkersville

For those completing 6th grade through those completing 8th grade

Cost: $20.00 per child for two weeks

Dates: June 10 – 21, Monday – Friday

Times: 9:30 – 3:00

Middle School Summer Enrichment Camp Registration

STUDENT INFORMATION

Student's Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Child's School(Required)

Grade Completed This Year(Required)

Child's Age(Required)

Reading Level(Required)

Is there something specific you would like for us to know about your child?

HEALTH INFORMATION

My child has medical conditions(Required)

Yes

If your child takes daily medication for the above medical conditions, list them here:

Does your child have any behavior issues that we should know about?

Camper who currently reside within the United States, a United States territory, or the district of Columbia; does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?(Required)

Yes

Electronic Parent Signature(Required)

EMERGENCY CONTACT INFORMATION

Parent/Guardian Name (1)(Required)

First Last

Relationship to Child(Required)

Cell Phone(Required)

Work Phone

Parent/Guardian Name (2)(Required)

First Last

Relationship to Child(Required)

Cell Phone(Required)

Work Phone

Additional Contact Name

First Last

Cell Phone

Work Phone

PHOTO/VIDEO RELEASE

I give permission for a photos or videos of my child to be shared for the Mission's promotional use (social media, website, newsletter).(Required)

Yes

Electronic Parent Signature(Required)

Date(Required)

OFFSITE ACTIVITY CONSENT

Electronic Parent Signature(Required)

Date(Required)

PARENT AGREEMENT

I understand that in order to hold my child’s spot, the non-refundable amount due ($20) must be paid in full and all paperwork must be signed and completed. This program operates on a ﬁrst come, ﬁrst serve basis. Make checks payable to Frederick Rescue Mission, and send your check, along with this application to: The Frederick Rescue Mission Attention: SEC/Teri Kwiatek P.O. Box 3389 Frederick, MD 21705

Electronic Parent Signature(Required)

Date(Required)

PAYMENT INFORMATION

If paying with a credit card, enter your billing information below. You will be redirected to PayPal to complete payment upon clicking the “Submit” button.

SEC Registration Price

Price: $60.00

Registration Total

Name on Credit Card(Required)

First Last

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Payment Method(Required)

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name