IWRBR Shively Summer Camp Registration Form
Shively Summer Camp
4703 Quinn Dr.
8:00 a.m. - 6:00 p.m.
M-F
June 1st- July 30th
$25 Registration fee
$95 per week
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Student Name
Student Birthday:
MM
/
DD
/
YYYY
Student Grade
What school does your child currently attend?
Does your child have an active IEP or 504 plan?
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Is there anything you would like us to know about your child?
Who will be providing transportation? *
Parent/Guardian Name:
Parent/ Guardian phone number:
Parent/ Guardian email:
Emergency Contact Name:
Emergency Contact Phone Number:
Does your child take any medications that will need to be administered during NTI camp hours?
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Preferred Payment Method for $25 Registration Fee (Payment will reserve your child's spot)
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I Would Rather Be Reading is a local non-profit organization whose mission is to provide equitable access to literacy instruction, enrichment opportunities, and advocacy. In order to provide affordable programming to families and students, we depend on the generosity of local donors, organizations, and individuals. We are very active on social media, frequently posting pictures and videos to keep donors engaged and to secure continued financial support for programming. Please type your name below to acknowledge your consent for IWRBR to use pictures and videos of your child/ren on any and all social media, website, and marketing materials.
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