21st Century Community Learning Center - Summer Camp 2024
Camp is open to all current New Haven Mustangs Students
Please fill out a seperate form for each child.
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FAMILY INFORMATION
Please provide the following information in regards to your family.
Primary Parent/Guardian Name
Primary Parent/Guardian home or Cell Phone Number
Primary Parent/Guardian Email Address: 
Primary Home Address: 
AUTHORIZED PEOPLE
Authorized people (other than parent/guardian) who can pick up your child - note that these individuals will be contacted if you are unable to pick up your child.
Name of Individual Authorized to pick up your child: 
Phone Number: 
Name of Individual Authorized to pick up your child:
Phone Number:
Name of Individual Authorized to pick up your child:
Phone Number:
STUDENT's INFORMATION
Please provide the following information for your child
Student Name
Current Grade ('23-'24 school year)
Homeroom Teacher (current)
TRANSPORTATION
Please provide information about how your child will get home from the program.
How will your child(ren) get to and from the camp?
Clear selection
Alternate address for student bus drop off, if different than primary address:
Weeks your child will attend Camp
Please select the weeks that your child will attend.
Weeks and Themes - (check all those that apply) Please note that Weeks 1 & 2 are for students currently enrolled in grades K-8. Weeks 3 & 4 are for grades K-5 only.
Field Trips
Check all that apply:

By checking the boxes below, I hereby give permission for my child to participate in the below-mentioned school-related student trip(s).

If I elect to drive my child to and from the school-related activity in my private vehicle, I understand that the Board’s insurance does not cover private vehicles and that my private vehicle insurance shall provide primary liability coverage in case of an accident. 

In addition, in the event my child suffers an accident or sudden illness while on the school-related student trip, I authorize school personnel to contact the physician(s) listed on my child’s school enrollment data forms and authorize those physician(s) to render such treatment as may be deemed necessary in an emergency for the health of said child. In the event that I, the physician(s), or other persons I’ve designated cannot be contacted, school personnel are hereby authorized to take whatever action is deemed necessary in their judgment for the health of said child.


PARENT/GUARDIAN AUTHORIZATION
I consent to authorize the 21st Century Program to photograph and/or video my child for the purpose of news stories, newsletters, brochures, website and/or social media pages. *
By submitting this form, I give permission for Nelson County Schools to share my child(ren)'s academic performance records for input into the 21st Century data-base for the purpose of tracking program progress.  I understand that this information will be kept strictly confidential and will NOT be used for any other purpose.                                                                                           Please place your name to serve as a signature in submitting this form: *
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