Summer Camp Registration

Summer Camp Registration.

Complete all sections below to register your child for the free Mr. Mack Lewis Foundation Summer Camp. Open to East Baltimore youth ages 8–18. Questions? Contact the foundation or call (443) 449-5690.

THE MR. MACK LEWIS FOUNDATION

Annual Free Summer Camp Application

913 N. Bond Street, Baltimore, MD 21205

Phone: (443) 449-5690 | Website: mrmacklewisfoundation.org

Camp Enrollment Information

Enrollment Date *

Days of Attendance *

MondayTuesdayWednesdayThursdayFridayWeekend / Special Program

Hours Attending *

Meals Child Will Receive

BreakfastLunch

Child Information

Child's Last Name *

Child's First Name *

Date of Birth *

Age *

Shirt Size

Sex / Gender

MaleFemalePrefer not to answer

Other:

Permanent Resident?

YesNo

Birthplace

Child's Home Address *

City *

State *

ZIP Code *

Optional Demographic Information

This information may be used for program reporting and funding purposes.

Black / African AmericanHispanic / LatinoWhite / CaucasianPuerto RicanAmerican Indian / Alaska NativeAsianKorean / ChineseOtherPrefer not to answer

Parent / Guardian Information

Parent / Guardian Name *

Relationship to Child *

Phone Number *

Email Address

Authorized Pickup Person

Authorized Pickup Name *

Relationship to Child *

Phone Number *

Emergency Contacts

Emergency Contact 1 *

Last Name

First Name

Phone Number

Relationship

Emergency Contact 2

Last Name

First Name

Phone Number

Relationship

Health & Safety Information

Date of Last Physical

Recommendations / Medications / Allergies

Food Allergies

Please list any medical, social, emotional, or behavioral concerns we should be aware of:

Permission & Liability Waiver

Meal Permission

My child named above has my permission to participate in The Mr. Mack Lewis Foundation Summer Camp and to receive breakfast, lunch, snacks, or meals prepared or provided through the program. I understand that if my child has allergies, dietary restrictions, medical conditions, or food-related concerns, I am responsible for informing The Mr. Mack Lewis Foundation Summer Camp staff before my child participates.

I grant meal permission *

Assumption of Risk & Liability Release

I understand that participation in summer camp activities may involve physical activity, recreation, meals, group activities, and other supervised programming. I understand that these activities may involve some risk of injury or illness.

I agree to assume responsibility for any property damage, injury, or incident caused by my child while participating in the Summer Camp Program.

I further understand and agree that this waiver and assumption of risk is binding on me, my child, my heirs, legal representatives, and assigns.

I release and hold harmless The Mr. Mack Lewis Foundation, its board members, staff, volunteers, partners, agents, representatives, and affiliates from claims, liability, damages, injuries, or losses that may arise from my child's participation in the Summer Camp Program, to the fullest extent permitted by law.

Parent / Guardian Consent: I certify that I am the parent or legal guardian of the child listed above. I give permission for my child to participate in The Mr. Mack Lewis Foundation Summer Camp. I have read and understand this application, meal permission, assumption of risk, and liability release. I understand that this document is legally binding for both myself and the child listed above.

I have read and agree to the liability release and waiver *

Parent / Guardian Consent & Signature

By typing your name below, you are providing your electronic signature, which is legally binding. You certify that you are the parent or legal guardian of the child listed above and have the authority to enroll the child in this program.

Parent / Guardian Name (Type full name as signature) *

Date *

By submitting this form, you agree that your electronic signature is legally binding.