After-School Program Application (1st-6th) Choose your camp location* Freedom – 19802/North Side (1000 E 28th St, Ricks Rock) Hope – 19801/South Bridge (455 Townsend St, Mt Joy UMC) Victory – 19801/East Side (800 N Walnut St, Ezion Mt Carmel UMC) Promise – 19805/West Side (800 N Walnut St, Ezion Mt Carmel UMC) UP Camps are intended for children who live in the immediate community surrounding each camp. Please select the camp that is located within the geographic area of your home address.Child's Name* First Last Age*Grade Entering*Birthday* MM slash DD slash YYYY School*Home Address* Street Address Address Line 2 City ZIP / Postal Code Medical Considerations:*Allergies (food and/or medication):*Disabilities and/or IEP*Court/Legal Matters:*Does this household receive WIC or SNAP?* Yes No Prefer not to say Gender:* Male Female Race* American Indian or Alaskan Native White Black or African American Native Hawaiian or other Pacific Islander Asian Other Race Non Disclosed Ethnicity* Hispanic or Latino Not Hispanic or Latino Non Disclosed Contact InformationParent/Guardian* First Last Relationship*Parent's Email Cell Phone*Work Phone2nd Emergency Contact (if parent isn't reachable):* First Last Relationship to Child(ren)*Home/Cell Phone*Additional Children(living at the same address who will be attending camp)Child's Name First Last AgeBirthday MM slash DD slash YYYY SchoolGrade EnteringMedical Considerations:Allergies (food and/or medication):Disabilities and/or IEPCourt/Legal Matters:Gender: Male Female Race American Indian or Alaskan Native White Black or African American Native Hawaiian or other Pacific Islander Asian Other Race Non Disclosed Ethnicity Hispanic or Latino Not Hispanic or Latino Non Disclosed Additional Children(living at the same address who will be attending camp)Child's Name First Last AgeBirthday MM slash DD slash YYYY SchoolGrade EnteringMedical Considerations:Allergies (food and/or medication):Disabilities and/or IEPCourt/Legal Matters:Gender: Male Female Race American Indian or Alaskan Native White Black or African American Native Hawaiian or other Pacific Islander Asian Other Race Non Disclosed Ethnicity Hispanic or Latino Not Hispanic or Latino Non Disclosed My child(ren) will:My child(ren) will:* walk home alone from camp be picked up by someone they will be picked up by…Please carefully read the following and then sign the agreement on the registration form:* I give permission for my child to participate in the activities sponsored by UrbanPromise and other cooperating organizations in the neighborhood. * In case of medical emergency, I understand that an effort will be made to reach me. However, I do give permission for the staff of this program to authorize emergency medical care for my child. * I understand the risk involved in this program and that the staff will exercise all reasonable care for my child. I will not hold UrbanPromise Ministries, Inc. or other cooperating organizations, their staff or representatives, responsible for injuries which occur to my child. * I understand that Christian education is part of the UrbanPromise camp program. * I understand that UrbanPromise and the cooperating organizations are not responsible for my child until and unless they arrive at the program site and/or after they have left the site. * I give permission for my child’s name and photograph to be used in publications produced by UrbanPromise Ministries, Inc. * I agree to support my child and the staff of this program through accepting and enforcing the discipline structure that is used. Δ
