Lights On Summer Camp Registration Form
Please complete this form if your student(s) plan on attending summer Lights On.

We are still currently unaware of start/end dates, duration, and what the instruction method will be for summer camp...we are working on a plan to ensure students have a safe and FUN environment this summer.

We will continuously update you as we find out more information! Please fill out this registration form for each of the student(s) you are interested in having attend summer camp. We will not be offering summer camp to Kindergarteners this year, and upcoming 5th graders will be attending RWE summer camp.

Just as a reminder, space may be limited if we offer in-person camp due to safety restrictions but blended learning is also a likelihood.

If you have any questions/concerns please contact Program Coordinator Julia Scott at or 856-655-8612. Thank you!!
Email address *
Student Legal First and Last Name
Student Date of Birth
Student Grade
Student's Homeroom Teacher
Mailing Address
Parent/Guardian Phone #
Primary Language(s) Spoken at Home
Student Lives With ...
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Mother/Guardian Name, Phone #, Email, and Physical Address
Father/Guardian Name, Phone #, Email, and Physical Address
Does your child need to borrow a chromebook to use for summer camp blended learning? *
Student T-Shirt Size
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Emergency Contact 1 Name & Phone #
Emergency Contact 2 Name & Phone #
Pick Up Options
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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.
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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
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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.
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Are there any current medical conditions/ allergies and does your child require any special accommodations? *
I give permission for my student’s image or likeness, and or recorded voice to be used by “Lights On” for the purpose of demonstrating, promoting, informing the public of “Lights On” activities.
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By typing your full name below, you agree to all terms and items listed above. *
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