Middle School After School Program Registration |

Choose your camp location*

Harmony - 19802/North Side (2616 Carter St, Union Baptist Church)
Amen - 19801,19805/South Bridge, East Side, West Side (408 E 8th St, Peoples Settlement)

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*

Birthday*

School*

Grade*

Home Address*

Street Address Address Line 2 City ZIP / Postal Code

Home Phone*

Medical Considerations:*

Allergies (food and/or medication):*

Disabilities and/or IEP*

Court/Legal Matters:*

Gender:*

Male
Female
Non Disclosed

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

Program Season:*

Summer Camp
Afterschool Program
Both

Contact Information

Parent/Guardian*

First Last

Relationship*

Parent's Email

Cell Phone*

Work Phone

Emergency Contact (if unable to reach parent):*

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

Age

Birthday

Grade Entering

Medical Considerations:

Allergies (food and/or medication):

Disabilities and/or IEP

Court/Legal Matters:

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

Program Season:

Summer Camp
Afterschool Program
Both

Additional Children

(living at the same address who will be attending camp)

Child's Name

First Last

Age

Birthday

Program Season:

Summer Camp
Afterschool Program
Both

Grade Entering

Medical Considerations:

Allergies (food and/or medication):

Disabilities and/or IEP

Court/Legal Matters:

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

Program Season:

Summer Camp
Afterschool Program
Both

Take Homes

My child(ren) will:*

walk home alone from camp
be picked up by someone

they will be picked up by...

Please read, check that you agree

I have read the information and regulations sheet and agree to uphold and support the standards, rules, and guidelines as outlined by UrbanPromise

My home address meets the eligibility requirements of my chosen camp locations

I understand that all field trip fees must be paid by June 25th in order for my child to participate in the trips.

I understand that my child will need to wear an UrbanPromise T-shirt for all camp field trips

I understand that my child will not be allowed to walk home from camp unless indicated aboce, and will only be able to be picked up by those listed above. Any changes must be communicated to the director.