Good Neighbors June Summer Day Camp Application
*Para solicitar la aplicación en español, llame a la oficina de su escuela.
*For Spanish application, please call your school office.

This camp is hosted in partnership by Franklin County Public Schools and SML Good Neighbors, Inc. The program is FREE and provides academic remediation in reading and math with FCPS teachers and a camp experience with SML Good Neighbors. Camp activities include art, gym, reading buddies, story time, enrichments in nature education, peaceful living and cultural diversity and global education. Daily breakfast, lunch and snack is provided. Each child will be given a weekend bag each week which contains a new book and food for the weekend (if you are not in need of additional food, please share it with someone who can use it).

Who: The 2021 summer day camp will be for students who attend Boones Mill, Burnt Chimney, Dudley, Glade Hill, Sontag and Windy Gap Elementary Schools.

When: June 14th - July 1st (Monday through Thursday); 8am - 3pm

Where: Burnt Chimney Elementary School (bus transportation will be arranged by FCPS transportation department for students who submit their application by April 23, 2021)

Priority will be given to students in need of remediation and returning campers, then first come first serve. Applications are due by April 23, 2021. If you are unable to complete this electronic application, please request a paper application from your school.

FCPS health safety precautions and guidelines will be in place for this program (including face coverings, temperature checks, social distancing, etc... - visit frco.k12.va.us for more information).
Student first and last name *
Student's Current Grade for the 2020-2021 School Year *
Student's Date of Birth *
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Student's School *
Parent(s) / Guardian(s) First and Last Name(s) *
Home Address (Street Address, City, Zip). If there is a different address for bus transportation, please specify. *
Parent / Guardian Email Address *
Parent / Guardian Cell Phone Number *
Parent / Guardian Home / Work Number *
Student's T-Shirt Size *
Photos or Videos of my child can be used for publicity: *
I, the parent/guardian undersigned, do hereby authorize the exchange of information between my child’s school and SML Good Neighbors, Inc.; including but not limited to: report cards, cumulative records, attendance and discipline records, grades, test results, IEPs, 504 plans, psychological and medical information, income and free and reduced lunch information, hearing/eye screening, etc…; do hereby state that I have read and received a copy of the Summer Day Camp Discipline Policy; and I release SML Good Neighbors, Inc. from any and all claims for losses or articles and damages arising as a result of any accident, injury by the named child arising from participation in SML Good Neighbors activities. Further, should an injury or illness be sustained, I hereby authorize SML Good Neighbors to administer first aid, or seek medical attention, in the event that I, as parent or guardian, cannot be reached. BY TYPING MY NAME BELOW to serve as my electronic signature, I confirm the information contained on this form, approvals and consents are accurate and consent to the above stated. *
Do you grant permission for the nurse to access your child’s school healthcare records? *
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