Youth Camp Application Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

STEAM Max Camps are designed for children ages 8-14 and participants for these camps must fit within this age range. Components of the class include science, technology, engineering, art and math. Camps are from 8am until 3pm each day. Please plan for timely drop-off and pick-up. Lunch will be provided each day.

Public Safety Careers Camp is designed for children ages 9-12 and it explores careers in public safety areas including fire, law enforcement, emergency medical services, and emergency management. Each day campers will enjoy demonstrations from multiple local public safety departments and have fun participating in hands-on activities. All attendees will come away with better understanding of public safety career opportunities as well as safety tips and skills.

Register your child here or in person at Van Dusen Hall at Sandhills Community College. You will need to return required signed document. Questions? Contact Danaka Bunch, bunchd@sandhills.edu or call 910-695-3980.

Which camp(s) are you interested in?

Student First Name *

Student Last Name *

Student Middle Name

Mailing Address *

City *

State *

Zip Code *

Student Date of Birth *

YYYY

Age *

Highest Grade Completed *

Gender *

Race *

Child T-Shirt Size *

Parent Name *

Parent Email Address *

Parent Cell Phone *

Parent Work Phone

In Case of Emergency Contact Name *

In Case of Emergency Contact Phone Number *

In Case of Emergency Contact Relationship to Student *

In Case of Emergency Contact Name 2

In Case of Emergency Contact Phone Number 2

In Case of Emergency Contact Relationship to Student 2

Name of Person with Permission for Pickup *

Relationship to Child of Person with Permission for Pickup *

Name of Person with Permission for Pickup 2

Relationship to Child of Person with Permission for Pickup 2

I will be responsible for picking up my child promptly at the end of class. *

Yes

Required

EMERGENCY MEDICAL TREATMENT

Please provide information of any medical or behavioral conditions, allergies, medications, or special needs of your child of which the staff and faculty should be aware

In the event that my child should require emergency medical treatment and reasonable attempts to contact me have been unsuccessful, I give my consent for emergency medical treatment deemed necessary by the licensed physicians or dentists at a nearby medical facility of preference. *

Yes

Required

Name of Insurer *

Policy Number *

Family Physician *

Phone Number *

How did you hear about our youth enrichment offerings?