SPRING BREAK CAMP 2020

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Register here for Spring Break Camp 2020

Dates: March 16th -20th, 2020
Location: Kennedy Community Center, 2800 S. D Street, Stockton, CA 95206
Hours: 10 am - 5 pm
Cost: FREE

Let your child be active, have fun and learn during Spring Break. Our FREE 5-day camp is for kids ages 9 - 15. Our campers will spend a week doing activities that are not only fun, but will also help them learn new skills, set and achieve goals, and build self-confidence. Please complete this form to register your child for our Spring Break Camp.

Lunch and snacks are provided!

A 1-day field trip is also included.

SPACE IS LIMITED,!! Registrations will be accepted on a first-come basis. So register now!

Once we receive your information, we will confirm your registration. If you have any questions, please call our office at ( 209) 229-4559.

Email *

Date of Request

YYYY

Youth's First Name *

Youth's Last Name *

Participant's Age (ages 9-15 only) *

Participant's Birthdate (make sure the year of birth is correct) *

YYYY

Home Address *

City *

If "Other" City, please list here

Zipcode *

Contact Phone Number (ie. xxx-xxx-xxxx) *

Other Phone Number (ie. xxx-xxx-xxxx)

Participant's School Name *

Is the Youth currently participating in a Sow A Seed program? (check all that apply) *

Anger Management

Boys to Men Conference

Boys Council

Fresh Start Thinking

Girls Circle

Kennedy Community Center ( after school program)

Mentoring

One-on-One Counseling / Family Thearpy

Summer Camp

Y.L.I.A ( Young Leaders in Action)

Other:

Required

Referred by *

Parent

School

Child Protective Services (CPS)

County Agency

Other:

Parent/ Guardian Name ( First, Last) *

Relationship to Youth *

Parent/Guardian phone number *

Parent/ Guardian email address *

Emergency Contact Name & phone number *

Number in Household *

Housing *

Youth's Sexuality *

Annual Income *

Does Youth Qualify for Free or Reduced Lunch Program at School? *

Yes

Source of Income (check all that apply) *

Tanf

SSi

Social Security

Pension

General Assistance

Unemployment

Employment & Other Sources

Employment Only

Other

Prefer not to answer

Required

Youth's Ethnicity (check all that apply) *

Asian

Black/African American

Hispanic/ Latino

Middle Eastern

Native American

North African

Pacific Islander

White

Other:

Required

I give permission for the participant listed above to participate in the Kennedy Community Center Spring Break program. I also waive, release and discharge all claims for personal and property damages arising from my child's participation *

Yes, I give permission. I am the parent /guardian of the participant listed above

No, I do not give permission. I am the guardian/guardian of the participant listed above

Required

I understand that by registering my child for this program that I am responsible for picking up my child, or arranging for someone to pick up my promptly by 5 pm each day. I am aware that after 2 late pick-ups ( arriving after 5 pm) that my child will be dismissed from the program. *

Yes, I will pick up my child by 5pm

Yes, I will have someone pick up my child by 5pm ( if checking this box, please complete the next section)

Required

The following persons have my permission to pick up my child from the program. Please include First and Last name and their phone number ( ex. Joe Blue 209-555-1122)

Please list allergies, dietary restrictions, medical conditions, or special accommodations needed for youth.

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