RWE Summer Camp Registration 2021
Please complete this form if your student(s) plan on attending summer Lights On.
Summer Camp will run from 12:30-5:30 PM Monday - Thursday for the following 6 continuous weeks:
Health protocols will be followed as directed by our school district nurse and county health official.
If you have any questions/concerns please contact Program Coordinator Julia Scott at
or 856-655-8612. Thank you!!
Student Legal First and Last Name
Student Date of Birth
Student Mailing Address
Parent/Guardian Phone #
Primary Language(s) Spoken at Home
Student Lives With ...
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
Mother/Guardian Name, Phone #, Email, and Physical Address
Father/Guardian Name, Phone #, Email, and Physical Address
Student T-Shirt Size
Emergency Contact 1 Name & Phone #
Emergency Contact 2 Name & Phone #
Pick Up Options
Pick up from designated contacts
Those authorized to pick up my student
Those NOT authorized to pick up my student
I give permission for my student to participate in all Lights On Afterschool sponsored activities, including field trips, water activities, and transportation during programming. HSCSD #1 and Lights On Afterschool is not responsible for any injuries or accidents that may occur. All precautions to keep students safe will be implemented. Parents will be notified of any instances within 24 hours. All students will be expected to follow school rules outlined in the school student handbook during Lights On Afterschool activities. If student refuses to follow these rules, they will be excused from the Lights On Afterschool Program.
I give permission for my student to participate in this 21 CCLC funded program required to have an anonymous teacher survey completed at the end of the school year for state reporting. Students will also participate in our evaluation system and complete surveys based on programming services
Yes, my student can participate in surveys
No, my student cannot participate in surveys
I give permission for the teacher and escort in charge to act on my behalf to take measures they deem necessary in the event of sickness or injury during a field trip or “Lights On” activity. I agree to pay for any medical expenses for the student whose name appears above.
Are there any current medical conditions and/or or allergies that your student has and does your student require any special accommodations for them?
I give permission for my student’s image or likeness, and or recorded voice to be used by “Lights On Afterschool” for the purpose of demonstrating, promoting/advertising, informing the public of “Lights On Afterschool” activities and academic enrichment opportunities.
By typing your full legal name below, you are agreeing to all terms and items listed above.
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This form was created inside of Hot Springs County School District #1.