2021 Application

Camper Name *

First

Last

Please select the week(s) of camp your child will attend: *

Week 1: June 1-18 (K-8) Back 2 Nature
Week 2: June 21-25 (K-8) Louisville Love: Exploring Our City's Past, Present, and Future
Week 3: June 28 - July 2 (K-8) Community and Compassion Camp
Week 4: July 12-16 (K-8) We Create Visual Arts Camp
Week 5: July 19-23 (K-8) STEAM Stars: Exploring Science, Technology, Engineering, Art, and Math

1st Parent/Guardian Name *

First

Last

1st Parent/Guardian Phone Number *

1st Parent/Guardian E-mail *

Full Family Address (street/city/state) *

Family Zip Code *

2nd Parent/Guardian Name

First

Last

2nd Parent/Guardian Phone Number

2nd Parent/Guardian E-mail

Annual Household Income *

We collect this information for grant reporting purposes.

Household size *

Financial Assistance

I would like to make the suggested donation of $100/week per child.
I would like to make a donation of a different amount.
I would like to forgo the suggested donation of $100 due to financial need.

A donation is not required to attend our camp. We provide a suggested donation amount only if you are interested in financially contributing to our program and supporting our efforts monetarily.

Emergency Contact Information

Emergency Contact #1 (other than parent/guardian) *

First

Last

Emergency Contact #1 Relationship to Child *

Emergency Contact #1 Phone Number *

This person is authorized to pick up my child

Emergency Contact #2 (other than parent/guardian) (copy) *

First

Last

Emergency Contact #2 Relationship to Child

Emergency Contact #2 Phone Number *

This person is authorized to pick up my child

Additional Persons Authorized to Pick-up My Child

Authorized Person #1 Name

First

Last

Authorized Person #1 Relationship to Child

Authorized Person #1 Phone

Authorized Person #2 Name

First

Last

Authorized Person #2 Relationship to Child

Authorized Person #2 Phone

Medical Information

Does your child have a diagnosed medical condition? *

Does your child have a learning or behavioral disability diagnosis? *

If you answered yes to one of the previous two questions please list diagnosis and any accommodations that would allow us to improve their experience

Does your child have an Individualized Education Program (IEP) or Behavior Intervention Plan (BIP)? If so are you willing to provide us with a copy?

These forms can list supports children use in schools to help them learn and strategies to help teachers understand behaviors.

Is your child currently taking any medications that will need to administered during camp times. If so, please list them here. Including name and dosage.

Please Explain

Medical Insurance Carrier *

Medical Insurance Phone *

Policy Number *

Group Number

Child's Physician *

Child Physician Phone Number *

List ALL allergies

Include nasal/respiratory, food, skin, any other our child has and please indicate the severity.

Epi-pen

Please check if your child requires an Epi-pen

Has anyone in you household traveled outside the U.S. in the past 180 days. If yes, please list all countries. *

Is you child current on all immunizations/vaccinations? *

Is there anything else about your child that you would like us to know?

Camper Information

Camper Gender

Camper Date of Birth (00/00/0000) *

Camper Age *

Camper Grade (as of the 2021-22) school year) *

Please enter the grade that the child will be entering in the 2019-2020 school year. Children must have completed Kindergarten to be eligible for K-3 camps.

Does your child receive free and reduced lunch? *

Camper Ethnicity

We collect this information for grant reporting purposes. Selection is optional if you wish not to identify.

Consent/Release

By checking each box you are providing your consent/release for each item.

In the Event of an Emeregency: *

I give permission to the UCHM staff to administer first aid and/or CPR and to select the nearest physician and/or hospital for my child's care.
I do not give permission to the UCHM staff to administer first aid and/or CPR and to select the nearest physician and/or hospital for my child's care.

In the Event of an Emergency (Continued): *

I give EMS and any other emergency transportation services permission to transport my child. I understand that this consent and release will apply to all emergency situations present and future.
I do not give EMS and any other emergency transportation services permission to transport my child. I understand that this consent and release will apply to all emergency situations present and future.

Other *

I give permission for my child to attend any UCHM sanctioned field trip during the United Learning Summer Camp. A list of field trips with locations, dates, and times will be provided to parents prior to start of camp. Campers are transported by UCHM staff using UCHM 15-passenger vans.
I do not give permission for my child to attend any UCHM sanctioned field trip during the United Learning Summer Camp. A list of field trips with locations, dates, and times will be provided to parents prior to start of camp. Campers are transported by UCHM staff using UCHM 15-passenger vans.

The United Learning Summer Camp includes 2-3 field trips per week. If you wish that your child not attend field trips, we cannot guarantee that we will have a staff member to remain on site during field trips.

Photo Release *

I give permission for my child's picture to be taken and used in UCHM's newsletter, social media, or other publicity materials. UCHM will not provide children's names or any other identifying information within any agency publication. Pictures will be used to share the work of UCHM with the community, donors, and supporters.
I do not give permission for my child's picture to be taken and used in UCHM's newsletter, social media, or other publicity materials. UCHM will not provide children's names or any other identifying information within any agency publication. Pictures will be used to share the work of UCHM with the community, donors, and supporters.

Date / Time *

Date

Time

Payment

Select Weeks for Payment

One Week of United Learning Summer Camp - $ 100.00
Two Weeks of United Learning Summer Camp - $ 200.00
Three Weeks of United Learning Summer Camp - $ 300.00
Four Weeks of United Learning Summer Camp - $ 400.00
Five Weeks of United Learning Summer Camp - $ 500.00

Total

$ 0.00

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