2021 Camp H.O.P.E. Enrollment Application
INSTRUCTIONS: Please complete one form for each child enrolled in the Camp H.O.P.E.Program. If requested information is non-applicable, mark N/A.  Completion of Kindergarten is a requirement for participation in this program. Applications MUST have the name of the school your child last attended for verification purposes. Applications will not be accepted without all information completed. Submission of this application does not guarantee your child’s enrollment. You will be contacted by a Camp H.O.P.E.Program staff with verification of enrollment. Please also note: Before/after care & transportation will be provided for those who currently qualify for DPS  bus transportation
Sign in to Google to save your progress. Learn more
Today's date *
MM
/
DD
/
YYYY
Parent/Guardian name (Last,First, MI) *
Cell Phone *
Alternative Number
E-Mail: *
Street Address ( include city, state, zip code) *
Additional Parent Information
Camp H.O.P.E requires income information for all families participating in the program. Please complete the following information in order to be eligible for enrollment in this program.

Relationship to Child *
Household income *
Household Size *
Does this child currently live with you *
Child's T-shirt *
Child's Name (First, MI, Last) *
Address (if not the same)
Child's Date of Birth (MM/DD/YEAR) *
MM
/
DD
/
YYYY
Preferred Name/Nickname *
Child's Gender *
What is your child's primary/native language (language spoken at home) *
Child's Race/Ethnicity (check one only) *
Required
Does your child have any siblings? *
Does this child have a sibling(s) who currently participates, or has participated in the Camp H.O.P.E program? *
How did you find out about Camp H.O.P.E. *
Required
What other academic enrichment or extra-curricular activities does your child participate in during the summer or academic school year (e.g. organized sports, music or dance lessons, academic tutoring, clubs, after school program, etc.)? *
Does your child receive or qualify for free/reduced price lunch at school during the academic school year? *
What type of school does your child attend? *
Required
What is the name and location of the school your child attended during the 2020-2021 academic school year?
Name of school: *
Street Address of school (include city, state, ZIP) *
What grade did your child complete during the most recent school year (2020-2021) *
Required
Has your child been in foster care at any point in his or her life? *
Child’s Academic Information
Does your child participate in any of the following educational programs (check all that apply)?   *
Required
Has a doctor, health professional, teacher, or school official ever informed you that your child has a learning disability? *
Has your child ever repeated a grade? *
Has your child ever attended a Freedom School or Camp H.O.P.E. summer program before? *
What Integrated Reading Curriculum (IRC) level will your child be enrolled in this summer? Use current grade level from 2020-2021 academic school year)? *
What is your child’s reading proficiency level? *
Media Consent? (photographs, videos, etc.) *
Child’s Medical Information
Does your child have health insurance? *
Primary Doctor (input N/A If not applicable) *
Primary Doctor telephone number (input N/A If not applicable) *
Preferred Hospital (input N/A If not applicable) *
Hospital Location (input N/A If not applicable) *
Has a doctor or health professional ever informed you that your child has any of the following medical conditions or disabilities? *
Required
Any developmental delay or physical impairment?(Please describe below or input N/A If not applicable) *
Does your child have any known medical conditions or disabilities that do not appear in the list above?       If so, please describe (input N/A If not applicable) *
Does your child have any dietary, allergenic, or exercise restrictions?If so, please describe. (input N/A If not applicable) *
Does your child currently need or use medication prescribed by a doctor? *
Is your child limited or prevented in any way from participating in moderate to strenuous physical activity? *
During the past 12 months, have you been told by a doctor or other health professional that your child had any of the following conditions? *
Required
Has your child been to the dentist in the last 12 months? *
Has your child been to an optometrist within the past 12 months? *
If there is anything else that you would like to share about your child, please indicate here.  (input N/A If not applicable) *
Emergency Contact Information
Emergency contact name (First, Last) *
Emergency contact's relationship to you *
Required
Emergency contact (First, Last) *
Emergency contact main phone number *
Emergency contact alternative number
Emergency contact home address *
Emergency contact relationship to child *
Please LIST ALL other adults who are authorized to pick up your child. (include name, their relationship to the child, and their mobile phone number) (input N/A If not applicable) *
Additional adult #1who is authorized to pick up your child main phone number, home address, AND relationship to child (input N/A If not applicable) *
Additional adult #2 who is authorized to pick up your child main phone number, home address, AND relationship to child (input N/A If not applicable)
Additional adult #3 who is authorized to pick up your child main phone number, home address, AND relationship to child (input N/A If not applicable)
Would you be willing to provide feedback regarding your child’s Camp H.O.P.E. Summer experience *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms