Summer Enrichment Camp Frederick

I'd like to register my child for the 2022 Summer Enrichment Camp in:*
- Frederick – June 20 – July 21st Monday – Thursday camp
Space is limited so register soon, payment will ensure your child’s enrollment!
Student Information
Student's Name*
Date of Birth*
MM slash DD slash YYYY
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child's School*
Grade just completed*
Child's Age*
Reading level*
Is there something specific you would like for us to know about your child?*
Health Information
My child has medical conditions*
- Yes
- No
If you answered YES, please specify below (INCLUDE ALLERGIES) or dietary restrictions:*
If your child takes daily medication for the above medical conditions, list them here:
Does your child have any behavior issues that we should know about?
Camper who currently reside within the United States, a United States territory, or the district of Columbia; does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?*
- Yes
- No
Please List*
Electronic Parent Signature*
Emergency Contact Information
Parent/Guardian Name (1)*
Cell Phone*
Work Phone
Parent/Guardian Name (2)*
Cell Phone*
Work Phone
Additional Contact Name
Cell Phone
Work Phone
Photo/Video Release
I give permission for a photos or videos of my child to be shared for the Mission's promotional use (social media, website, newsletter).*
- Yes
- No
Electronic Parent Signature*
Date*
MM slash DD slash YYYY
Oﬀ-Site Activity Consent
I give permission for my child to walk to a nearby park or event site on daily outings. I am also aware that my child can/will participate in ﬁeld trips throughout the 2022 Summer Enrichment Camp.
Electronic Parent Signature*
Date*
MM slash DD slash YYYY
Parent Agreement
I understand that in order to hold my child's spot, the non-refundable amount due ($60) must be paid in full and all paperwork must be signed and completed. This program operates on a ﬁrst come, ﬁrst serve basis. Make checks payable to Frederick Rescue Mission, and send your check, along with this application to: The Frederick Rescue Mission Attention: SEC/Teri Kwiatek P.O. Box 3389 Frederick, MD 21705
Electronic Parent Signature*
Date*
MM slash DD slash YYYY
SEC Registration
Price:
Online Payment
- Pay with Credit Card
Payment Information
If paying with a credit card, enter your billing information below.
You will be redirected to PayPal to complete payment upon clicking the "Submit" button.
Name on Credit Card*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
This field is for validation purposes and should be left unchanged.

Student Information

Health Information

Emergency Contact Information

Photo/Video Release

Oﬀ-Site Activity Consent

Parent Agreement

Payment Information