Summer Day Camp Registration For seven weeks after the school year ends, Summer Day Camp gives our youngest members a place to go to have fun and grow in a nurturing environment. Members ages 7 to 12 participate in our camp Monday through Friday from 9:00 am to 5:30 pm. Primary Information Child's First Name M.I. Last Name Address Apt Phone City State Zip Date of Birth Age Gender MaleFemale Emergency Contacts Name Relationship Phone Name Relationship Phone Parent(s)/Guardian(s) Mother/Guardian First Name: Last Name Work Phone Cell Phone Father/Guardian First Name: Last Name Work Phone Cell Phone Escort Information I, [parent] (name of parent), authorize my child, [child], to travel UNESCORTED FROM The Brotherhood/Sister Sol Summer Day Camp to home. Name Relationship Phone Name Relationship Phone Name Relationship Phone I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above statement. Health Information Childโs Health Problems (please be specific) Does your child have any special needs? Does your child have any Dietary Restrictions? NoYes Does your child have asthma? NoYes Does your child have any allergies? NoYes Emergency Information In case of any emergency, I give my consent for The Brotherhood/Sister Sol to obtain emergency medical treatment for my child. My Insurance ID My Medicaid # Additional Information When did you become a member of the organization? Month Year What program do you participant in? (Check all that apply) The Rites of Passage Program The After School Program The Liberation Program The Summer Leadership Program (Summer Day Camp, YEO, ISP) What were your grades at the end of the school year? Mostly As and Bs or 90-100 Mostly Bs and Cs or 70-89 Mostly Cs and Ds or 65-79 Mostly Ds and Fs or 65 or below What is your ethnicity? Black/African American Caribbean Black Latino Asian/Pacific Islander Multiracial White Other What languages are spoken in your home? English Spanish French Creole Multiracial White Other Do you or your family receive any of the following (check one of each)? Public Assistance Yes No Don't Know Food Stamps Yes No Don't Know Household Income $0-$40,000 $40,001-$65,000 $65,001-$80,000 $80,001-$95,000 $95,001-up Who in your family has completed high school? Who in your family has completed College? Signature I, (parent), give permission for my child to participate in The Brotherhood/Sister Sol Summer Day Camp. I release The Brotherhood/Sister Sol from any liability for any injuries my child may incur while engaging in any of the Summer Day Camp activities or trips. Programs » Summer Leadership Program » Summer Day Camp » Summer Day Camp Registration