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 InformationStudent'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 InformationMy 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 InformationParent/Guardian Name (1)* Cell Phone*Work PhoneParent/Guardian Name (2)* Cell Phone*Work PhoneAdditional Contact Name Cell PhoneWork PhonePhoto/Video ReleaseI 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 ConsentI 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 AgreementI 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 21705Electronic Parent Signature* Date* MM slash DD slash YYYY SEC Registration Price: Online Payment Pay with Credit Card Payment InformationIf paying with a credit card, enter your billing information below. 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