2021 Application Please enable JavaScript in your browser to complete this form.Camper Name *FirstLastPlease select the week(s) of camp your child will attend: *Week 1: June 1-18 (K-8) Back 2 NatureWeek 2: June 21-25 (K-8) Louisville Love: Exploring Our City's Past, Present, and FutureWeek 3: June 28 - July 2 (K-8) Community and Compassion CampWeek 4: July 12-16 (K-8) We Create Visual Arts CampWeek 5: July 19-23 (K-8) STEAM Stars: Exploring Science, Technology, Engineering, Art, and MathAll camp participants will receive a 2020 United Learning Camp T-shirt. Please select T-shirt size: *Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLarge 1st Parent/Guardian Name *FirstLast1st Parent/Guardian Phone Number *1st Parent/Guardian E-mail *Full Family Address (street/city/state) *Family Zip Code *2nd Parent/Guardian NameFirstLast2nd Parent/Guardian Phone Number 2nd Parent/Guardian E-mailAnnual Household Income *We collect this information for grant reporting purposes. Household size *Financial AssistanceI 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 InformationEmergency Contact #1 (other than parent/guardian) *FirstLastEmergency Contact #1 Relationship to Child *Emergency Contact #1 Phone Number *This person is authorized to pick up my childEmergency Contact #2 (other than parent/guardian) (copy) *FirstLastEmergency Contact #2 Relationship to ChildEmergency Contact #2 Phone Number *This person is authorized to pick up my childAdditional Persons Authorized to Pick-up My ChildAuthorized Person #1 NameFirstLastAuthorized Person #1 Relationship to ChildAuthorized Person #1 PhoneAuthorized Person #2 NameFirstLastAuthorized Person #2 Relationship to ChildAuthorized Person #2 Phone Medical InformationDoes your child have a diagnosed medical condition? *YesNoDoes your child have a learning or behavioral disability diagnosis? *YesNoIf you answered yes to one of the previous two questions please list diagnosis and any accommodations that would allow us to improve their experienceDoes 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 ExplainMedical Insurance Carrier *Medical Insurance Phone *Policy Number *Group NumberChild's Physician *Child Physician Phone Number *List ALL allergiesInclude nasal/respiratory, food, skin, any other our child has and please indicate the severity. Epi-penPlease check if your child requires an Epi-penHas anyone in you household traveled outside the U.S. in the past 180 days. If yes, please list all countries. *YesNoIs you child current on all immunizations/vaccinations? *YesNoIs there anything else about your child that you would like us to know?Camper InformationCamper GenderCamper 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? *YesNoCamper Ethnicity Black/African AmericanWhiteAsianAmerican Indian or Alaska NativeHispanic/LatinoNative Hawaiian or Other Pacific IslanderWe collect this information for grant reporting purposes. Selection is optional if you wish not to identify. Consent/ReleaseBy 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 *DateTimePaymentSelect Weeks for PaymentOne Week of United Learning Summer Camp - $ 100.00Two Weeks of United Learning Summer Camp - $ 200.00Three Weeks of United Learning Summer Camp - $ 300.00Four Weeks of United Learning Summer Camp - $ 400.00Five Weeks of United Learning Summer Camp - $ 500.00Total$ 0.00Paragraph TextSubmit