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AGAPE LIFE STEM SUMMER CAMP PROGRAM 8568 Laureldale Dr, Laurel, MD 20724 Phone: (301)-725-6525 or (301)-828-6664
AGAPE LIFE STEM SUMMER CAMP PROGRAM APPLICATION
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Email
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Your email
CHILD #1
First Name
*
Your answer
Last Name
*
Your answer
Birth Date:
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YYYY
Gender
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Female
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Grade
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Pre-K
Grade 1
Grade 2
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Grade 4
Grade 5
Grade 6
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Grade 8
Grade 9
Grade 10
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Grade 12
Ethnicity:
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African American
African
Asian
Native American
Caucasian
Other
Required
CHILD #2
First Name
Your answer
Last Name
Your answer
Birth Date:
MM
/
DD
/
YYYY
Gender
Male
Female
Grade
Choose
Pre-K
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ethnicity:
African American
African
Asian
Native American
Caucasian
Other
CHILD #3
First Name
Your answer
Last Name
Your answer
Birth Date:
MM
/
DD
/
YYYY
Gender
Male
Female
Grade
Choose
Pre-K
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Ethnicity:
African American
African
Asian
Native American
Caucasian
Other
Address:
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City
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State
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Zip Code
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Home Phone:
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Cell Phone:
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Work Phone:
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Emergency Contact Info (Contact Name):
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Phone Number
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Relationship to child:
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Allergies
Yes
No
If YES Please List
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PARENT
My child(ren) walks home
My child(ren) are picked up
My child takes public transportation
Authorized persons to pick up my child(ren) are : First & Last Name(s)
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Phone Number(s)
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If under 18 years of age please notify staff. My signature authorizes my child to be picked up only by the persons I have listed on this form unless otherwise notified in writing.
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