GEP Summer Camp Application

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Summer Sizzler 2023

Email *

Student Last Name *

Student First Name *

Student ID Number

Age *

Date of Birth *

YYYY

Gender *

Female

Male

The grade that your child is going to be in for the upcoming School Year (2023-2024) *

What school does your child attend? *

Do you need transportation? (pick and drop off) Please Note transportation is NOT available for Niner University and Movement Charter school *

Yes

Name of apartment complex if applied *

T-Shirt size *

Youth Small

Youth Medium

Youth Large

XXL

Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

Mother First Name *

Mother Last Name *

Address *

City *

State *

Zip Code *

Mother Place of Employment (IF NONE TYPE NA)

Email Address *

Home Phone Number *

Mobile Phone Number *

Father First Name *

Father Last Name *

Father Address (if not known indicate NA) *

City *

State *

Zip Code *

Mobile Number (if not known indicate NA) *

Does your child have any food allergies or food restrictions? *

Does your child have IEP? (individual education plan) *

Yes

Does your child have any chronic illnesses or conditions that will prevent them from participating in summer camp activities? Note: GEP does not have the staff to accommodate children that require one on one care or care that requires special training. *

Yes

Other:

Program & Activities, I give my child permission to participate in all activities and virtual field trips. *

Yes

Greater Enrichment Program has accident insurance for all active GEP students while in the care of GEP. (Please indicate other medical insurance coverage). Insurance Company Name *

Policy # *

Telephone Number *

Emergency Care Information. Name of Child's doctor *

Doctor's Address *

Doctor's Phone Number *

Hospital Preferred *

1. Emergency contact name and phone number *

2. Emergency contact name and phone number *

PARENTAL PERMISSION, WAIVER, AND INDEMNITY FORM. AUTHORIZATION: *

I voluntarily grant the Greater Enrichment Program (GEP) and their funding agencies permission to gather all information it deems necessary in order to assist my child’s educational and social betterment. I understand that this information may include, but will not be limited to, any information maintained at any educational institution (specifically Charlotte-Mecklenburg Schools or Charter School) attended by my child; and any information obtained from any teacher or administrator at any educational institution attended by my child; and any information obtained from programs agencies or individuals providing any types of services to my child.

Required

PARENTAL PERMISSION, WAIVER, AND INDEMNITY FORM. AUTHORIZATION: *

I understand that GEP will only use such information for the purposes of my child’s participation in GEP activities and/or receipt of GEP services. More specifically, I authorize the release of such data from the school my child attends and other programs or agencies that provide assistance to my child. The information requested will include student/parent contact and profile information, immunization records, end of grade test scores, student ID numbers, and skill strengths and weaknesses as identified by CMS and Movement Charter School teachers.

RELEASE & WAIVER *

In consideration of the benefits which my child (the student) receives from participation in the Greater Enrichment Program: I hereby waive and release any right I may have a parent or guardian and any right the student might have to bring an action, claim demand, or suit against GEP, GEP Directors, Officers, Employees, Volunteers and Agents, and any agencies, organizations, programs or other entities with GEP for any actual or alleged act of negligence by Greater Enrichment Program or its funding sources, agents or employees

Required

RELEASE & WAIVER *

I understand and agree that I am solely responsible for any emergency medical attention rendered to or damages caused by the child. If GEP pays any money on behalf of my child due to injury sustained by the child or damage caused by my child, I agree to reimburse GEP in full for such payment. EMERGENCY SITUATIONS: In the event, my child requires emergency medical attention while participating in GEP activities or while receiving GEP services and I am unavailable to act on my child’s behalf or my child is in immediate danger

PHOTO RELEASE *

I grant Greater Enrichment Program (GEP) the unlimited right to use and/or reproduce photographs*, likenesses, or the voice of my child in any legal manner and for the internal or external promotional and informational activities of GEP. I also agree to allow my child to be interviewed and/or photographed* by representatives of the external news media, school staff, and GEP Communications Services in relation to any and all coverage of GEP in which he/she is involved. I also agree to allow my child’s work and/or photograph* to be published in any GEP communication, including web and intranet sites, social and broadcast media channels, and print and electronic publications. I further understand that by signing this release, I waive any and all present or future compensation rights to the use of the above-stated material(s) including, print, electronic and online media.

Required

SIGNATURE: I certify that all of the above information is true and correct and that All income is reported. I understand that this information is being given for the receipt of Federal funds and that Deliberates' misrepresentation of the information may subject me to prosecution under applicable State and Federal laws. I further understand it is my responsibility to keep this information updated with GEP as it changes. PLEASE WRITE YOUR NAME *

DATE *

YYYY

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