United Learning Summer Camp Application

Thank you for your interest in the 2019 United Learning Summer Camp. We are please to offer a number of fun and interactive camps to children in grades K-8. Please submit an application for each child you wish to enroll in the 2019 United Learning Summer Camp.

Important Information about the United Learning Camp program:

Camp runs 9:00am – 4:00pm daily at UCHM (150 South State Street, Louisville, KY 40206)
Drop off is between 8:45am – 9:00am, Pick-up is between 3:45-4:00pm.
The cost of the camp is $100 per week. Financial assistance is offered.
Campers bring a sack lunch, snack provided
Payment is due at the time of application unless you are submitting an application for financial assistance.

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

1st Parent/Guardian Name *

First

Last

1st Parent/Guardian Phone Number *

1st Parent/Guardian E-mail *

Full Family Address (street/city/state/zip) *

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.

Financial Assistance

I would like to apply for financial assistance

Financial assistance is offered on a case-by-case basis. A UCHM staff member will contact you to complete an application.

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

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

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

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.

Is you child current on all immunizations/vaccinations? *

Camper Information

Camper Name *

First

Last

Camper Gender

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

Camper Age *

Camper Grade (as of the 2019-2020 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.

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
Two Weeks of United Learning Summer Camp
Three Weeks of United Learning Summer Camp
Four Weeks of United Learning Summer Camp

Total

$ 0.00