United Learning Summer Camp Application

150 State Street, Louisville, KY 40206 5028930346

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United Learning Summer Camp Application

Thank you for your interest in the 2024 United Learning Summer Camp . We are pleased to offer a number of fun and interactive camps for children. Camp is open to all children and youth in grades 1-8 during June 10-June 14, after that date camp will only be eligible for JCPS in grades 1-8 due to our partnership with Evolve502’s Backpack league. Please submit an application for each child you wish to enroll in the 2024 United Learning Summer Camp. *Grades of eligibility are based on the 2023-2024 school year.*

Important Information about the United Learning Camp program:

Camp runs 9:30am – 2:30pm daily at UCHM (150 South State Street, Louisville, KY 40206)
Drop off is between 9:15am – 9:30am, Pick-up by 2:30pm.
We provide lunch and a snack.

Camper Name *

First

Last

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 *

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

Can your child walk home alone? *

Yes
No

How will your child be transported to and from the program? *

Car
Walk

Medical Information

Does your child have a diagnosed medical condition? *

Yes
No

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

Yes
No

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 your child has and please indicate the severity.

Does your child have any dietary restrictions? *

Yes
No

If you answered yes to the previous question, please list dietary restrictions

Epi-pen

Please check if your child requires an Epi-pen

Is you child current on all immunizations/vaccinations? *

Yes
No

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 *

School Child Currently Attends *

Camper Grade (as of the 2023-24) school year) *

Please enter the grade that the child will be entering in the 2023-2024 school year. Children must have completed Kindergarten to be eligible for camps.

Does your child receive free and reduced lunch? *

Yes
No

Do you need financial assistance to cover the cost of the registration fee? *

Yes
No

Will your child be bringing a lunch to camp each day? *

Yes
No

Camper Race

Black/African American
White
Asian
American Indian or Alaska Native
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
Multi-Racial
Other

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 walk to the Clifton Park for daily outdoors activities during the United Learning Summer Camp
I do not give permission for my child to walk to the Clifton Park for daily outdoors activities during the United Learning Summer Camp. There’s no gurantee a staff person will be available to stay on site with your child if they do not go to the park.

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

150 State Street Louisville, KY 40206

502-893-0346

uchmlouisville@gmail.com