Date *

MM

DD

YYYY

Student's Full Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Sibling's Name Attending Camp

optional

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Emergency Contact Atl. Phone

(###)

###

####

Informed Consent and Acknowledgement *

I hereby give my approval for my child’s participation in any and all activities prepared by (insert tutoring name here) during the selected camp. (insert tutoring name here) is not responsible for increased grades in school. However, we do guarantee providing each student with developmentally appropriate tasks, strategic lessons, and researched based content to improve their reading and/or math performance.

Agree

I do not agree

Media Disclosure

We may periodically photograph students participating and working during camp. These photographs may be used in a variety of ways; Public relations and marketing purposes: images printed on brochures, posters, and newsletters, or on (insert tutoring name here) Website, Facebook Page, and/or other art, education, or news related publications. Please indicate whether you will allow publication of photographs taken of your child/children and their literacy work during classes. Names will not be included in photographs or posted on social media. We appreciate your support and would love the chance to share pictures of all of the fun being had at our Summer Reading Camp. You can also follow us on Facebook to capture all of the pictures yourself!

Agree

I do not agree