LCCC 2022 Summer Camp Registration Form
Summer Camp will run from June 13, 2022 through July 29, 2022
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Email *
Summer Camp total fee is $350.   LCCC will take a check or money order.  Please include on the subject line your child's name and summer camp. Please contact LCCC if you have more than one child for a discount. *
First Name of Student *
Last Name of Student *
Date of Birth *
Age *
Last 4 numbers of youth's SSN *
Grade *
School Name *
First Name of Parent/Guardian *
Last Name of Parent/Guardian *
Child lives with *
Telephone Number *
Address   *
Zip Code *
Race *
Ethnicity *
Does your child have allergies? *
If yes, please list your child's allergies. If no, mark N/A *
Does your child have a medical condition we need to know about? *
If yes, please list your child's medical condition. If no, mark N/A. *
Emergency Contact: Name and Phone Number *
I give my consent for my child  to participate in the school-age youth activities at LCCC, Inc. I understand that I may withdraw my child from the program at any time. I agree to submit copies of academic records (report cards) to LCCC for tracking purposes. In the event that I do not supply these documents, LCCC has permission to request the documents from my child’s school. All children enrolled in LCCC programs must enroll in a minimum of 2 program activities. I agree to the terms of participation on behalf of my child. I understand that the school-age youth and LCCC are a parent/child team effort and agree to be involved in these programs. *
I hereby grant permission for the President/CEO of LCCC, Inc, or it’s staff acting on their behalf, to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps include, but are not limited to the following:1. Attempt to contact parent or guardian.2. Attempt to contact family.3. Attempt to contact parent or guardian through emergency contacts listed on the enrollment form.4. If LCCC staff cannot contact parents or guardians, they will do one of the following: a. Call a physician b. Call an ambulance. c. Take the child to the emergency room of a local hospital in the company of a staff person.5. Any expenses incurred under #4 will be the responsibility of the child’s parents/family. *
Mother's Full Name *
Mother's Date of Birth *
Father's Full Name *
Father's Date of Birth *
Youth's Pediatrician Name, Address and Phone number *
Emergency Contact's First and Last Name *
Emergency Contact Relationship *
Emergency Contact's Phone Number *
Field Trip Permission Release: The undersigned parent or guardian herby gives permission for my child, to accompany LCCC, Inc staff and/or volunteers on program field trips. Transportation will be provided by either commercial bus or LCCC van/mini-bus. In consideration of the advantages of field trips, the undersigned agrees that Louisville Central Community Centers, Inc, it’s agent, employees, driver and/or owner of the vehicle used for the field trip shall be exempt from liability as provided by law. *
Promotional Release Form: I agree to an interview, an audiovisual recording, or to have photographs taken of me by LCCC staff or persons authorized by LCCC for use by LCCC. I authorize the release and distribution of information concerning my activities at the agency, including photographs or audiovisual recordings to news media for the promotional use of LCCC. I release LCCC, its personnel, and any other persons from any liability connected with taking or use of such photographs, interview, or audiovisual recording. I grant this authorization and release because favor the promotion of LCCC and its agencies services. This agreement fully represents all terms and considerations, no other inducements, statements, or promises have been made. *
Please list your restrictions. If none, mark N/A *
Annual Household Income: Check one box *
STAFF RATING OF YOUTH BEHAVIOR PASSIVE CONSENT: Dear Parents/Guardians: LCCC Youth Services participates in Building Louisville’s Out-of-School Time Coordinated System (BLOCS), an initiative that aims to elevate the importance of social-emotional skills such as, responsibility, teamwork, and problem-solving. These are necessary skills to succeed in school, work, and life. As a part of this initiative, program sessions that your child attends will be observed twice over the program year. The lead instructor will rate your child’s social and emotional learning (SEL) behaviors twice throughout the program; once in the fall and once in the spring, using the Staff Rating of Youth Behavior (SRYB). The SRYB is a tool that is designed to help staff understand what areas of SEL growth is required. If you do not give permission, your child will not be rated by the instructor. All information collected will be kept confidential. No individual children or youth will be identified. We do not see any risks to you, or your child associated with participating. The information garnered will be used to improve our program and to generate greater support for other youth development programs in the community. Your participation is voluntary. We encourage all parents to agree to allow their children to participate so that we can have the most complete information possible about how our program is affecting children and youth. Please sign and return this form to us only if you DO NOT wish for your child to participate. If you have any questions about the SRYB, please contact us. *
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