Washington Street 21st Century Camp Registration Form
Thank you for registering. Questions with a red asterisk require an answer.
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Student's Last Name *
Student's First Name *
Student's Date of Birth *
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Student's Race *
Gender *
School *
Grade *
Lunch Status *
Is student English proficient? *
Does student receive Special Education Services with Newton County School System? *
Home Address *
City *
State *
Zip Code *
Student's Telephone Number
Parent/Guardian Name *
Parent/Guardian Email Address *
Parent/Guardian's Telephone Number *
Who does student live with? *
Is parent/guardian English proficient? *
Does your child have any food allergies? If yes, please list them.
Emergency Contact Name *
Emergency Contact Telephone Number *
Do you have a district issued Chromebook or Hot Spot? *
Does your child need transportation? (NOTE: students will be picked up/dropped off at designated stops near home. Door to door is not provided)
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Address for pick-up/drop-off
T-shirt size?
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Parent/Guardian Signature (by typing my name below, I am confirming that this information is true and accurate. I am also giving permission for my child to participate in the 21st CCLC Summer Camp with Newton County School System and be photographed for reporting and evaluation purposes). PLEASE TYPE YOUR NAME *
Date signed *
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