Rock Wit It Summer Camp Application

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The St. Paul AME Church is partially funded through public funds. In order to access these funds and allow us to provide low cost services to your child, our funders need the following information:

Last Name of Child: *

First Name of Child *

Middle Name of Child *

Child's Age: *

Date of Birth: *

YYYY

Child's Gender:

Female

Male

Prefer not to say

Other:

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Last 4 digits of child's Social Security Number (if available):

Public School ID# (if you do not have one or prefer not to answer please skip to the next question):

Child's Current School (2021 - 2022 school year):

Child's Current Grade:

Is your child proficient in English?

Yes

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Other Language(s) Spoken in the Home:

Child's Ethnicity:

Hispanic

Haitian

Other:

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Child's Race:

American Indian or Alaskan

Asian

Black or African American

Pacific Islander

White

Other:

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Please provide child's address. *

Does child have health insurance (ex., private insurance, KidCare, Medicaid)? If not, we may be able to help you find affordable coverage-call 211 or visit www.thechildrenstrust.org *

Yes

Parent/Guardian Name: *

Daytime Contact Number: *

Parent/Guardian Email: *

Number of children living in the household (including participant)? *

Is the Participant a Child of a Military Family? A member of the child’s family is either: 1) an active duty member of the uniformed services; 2) a member of the National Guard or reserves; 3) a member or veteran who was severely injured and medically discharged or retired; or 4) a member killed in the line of duty. *

Yes

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