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2026-2027 MSD BASE Camp Before School Registration Form
Please complete a separate form for each child attending.  Before school programming is available for any MSD of Steuben County student in grades K-8.  The MSD before school program will be held at Angola Middle School beginning at 6:30 am, Monday-Friday.  Program is free of charge.  Transportation to appropriate MSD schools will be provided at no charge to participants.  Breakfast will be available for purchase. Space is limited.  For additional questions, please contact Breann Fink at breann@steubenliteracy.org.
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Email *
Student's Last Name *
Student's First Name *
Date of Birth *
MM
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DD
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Age *
Fall 2026 Grade *
Fall 2026 Teacher, (if known)
STN (Student Testing Number), if known 
School *
Gender *
Address *
City *
Zip *
County *
Township *
Contact Phone *
Other Phone
Please list any medical conditions or allergies (including food allergies) *if food allergy exists, we must have a Dr.'s note on file stating the particular allergy and any necessary substitutions*
Lunch Status of Student (Please choose one) *
Race/Ethnicity (Check all that apply) *
Required
Is student disabled? *
Is student currently in foster care? *
If student is disabled, please list type of disability.
Parent/Guardian Last Name *
Parent/Guardian First Name *
Parent/Guardian Address *
Parent/Guardian City *
Parent/Guardian Zip *
Parent/Guardian Home Phone *
Parent/Guardian Work Phone
Parent/Guardian Cell Phone
Parent/Guardian Relationship to Student *
Parent/Guardian Occupation
Parent/Guardian Marital Status
Clear selection
Parent/Guardian Employment Status
Clear selection
Parent/Guardian Highest Level of Education
Clear selection
Primary Language Spoken at Home
Emergency Contact 1: Name *
Emergency Contact 1: Phone *
Emergency Contact 1: Relationship to Student *
Emergency Contact 1 (listed above) is authorized to pick up student? *
Emergency Contact 2: Name
Emergency Contact 2: Phone
Emergency Contact 2: Relationship to Student
Emergency Contact 2 (listed above) is authorized to pick up student?
Clear selection
Emergency Contact 3: Name
Emergency Contact 3: Phone
Emergency Contact 3: Relationship to Student
Emergency Contact 3 (listed above) is authorized to pick up student?
Clear selection
Additional Individuals Authorized to Pick-Up Student
Emergency Medical Care-I hereby state that I am the parent/guardian of a minor, who resides with me at the provided address.  I authorize anyone who is authorized to represent SCLC at an approved SCLC function, to consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the continental USA.  It is understood that this is for emergency medical treatment in the event that I am unable to be contacted. *
Child's Doctor *
Preferred Hospital for Emergency Medical Care *
I hereby consent to photographs, videos, motion picture films, and/or biographical information for which my child posed, and/or writings and/or audio recordings made of my child's voice to be used by Steuben County Literacy Coalition (SCLC), in whatever way they deem necessary for communication, media relations and advertising, which may include, but is not limited to, print media, social media, television, SCLC collaterals, SCLC advertising and SCLC website; furthermore, I hereby consent that such photographs, films, recordings or writings and the plates, tapes or discs from which they are made shall become the property of SCLC. SCLC shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, writings, social media, plates, tapes and disks as they deem necessary, free and clear of any claim whatsoever on my part. *
I have read the attached disclosures and releases of information, in regards to program policies and consent to all statements below. *
Required
By typing my name below, I agree that I am signing this document as the parent or guardian of the child above. *
A copy of your responses will be emailed to the address you provided.
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