Matheny-Withrow Elementary Camp Kindergarten Summer Program 2020
Please fill out the form below to register your child for the Camp Kindergarten Program.  If you have any questions regarding this form, please call the Camp Coordinator, Lacey Harrison, at 708-680-6767.
Email *
Student Name (First and Last): *
Parent/Guardian with whom the student lives: *
Street Address: *
Zip Code *
Phone Number: *
Work/Alternate Phone Number:
Student's Gender: *
Student's Race/Ethnicity: *
Age: *
Date of Birth: *
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How many people live in your immediate household? *
Please indicate your current household income: *
Emergency Contact Person #1: *
Emergency Contact #1 Relationship to Child: *
Emergency Contact #1 Phone Numbers: *
Emergency Contact Person #2: *
Emergency Contact #2 Relationship to Child: *
Emergency Contact #2 Phone Numbers: *
Student Medical Conditions or Allergies: *
Medications Being Taken (Please indicate if they need to be taken during school hours): *
Does the student have any previous pre-school experience? *
If so, what program did they attend?
How long did they attend the program?
In the morning, my child will be a... *
If they are riding the bus in the morning, the student will be picked up at this address:
In the afternoon, my child will be a... *
If they are riding the bus in the afternoon, the student will be dropped off at this address:
My child will attend Matheny-Withrow during the 2020-2021 school year. *
If selected, I will do my best to ensure my child's daily attendance at school. *
I give consent for my child to be included in any interviews, photos, videos, website, school news stories, informational projects, or programs. *
I understand that by signing this, I am committing my student to all of the dates of the camp in order for them to receive all that the program has to offer.  Daily attendance is important and the camp reserves the right to remove a student from the program if there are three or more unexcused absences in the first week of the program.  I also understand the District 186 Code of Conduct is in full force while my student is participating.  In the event of illness or accident to my child, and I cannot be reached, I authorize my child be provided with such first aid treatment, ambulance service, and/or emergency hospitalization as deemed advisable and necessary by school personnel.  I also consent to the release of my child’s academic and attendance records for data tracking and evaluation purposes to our evaluation and grant providers. *
By typing your name below, you are agreeing to the terms of the registration form. *
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