2023 Brookland-Lakeview 21st Century COLA Program
21st Century Community Learning Center |  Brookland-Lakeview Empowerment Center 

 Summer Camp Registration Form 

Child's Information

Has the child attended summer camp before? *
Does the child require any special accommodations? *
What is the child’s learning style/How does your child learn best? *

Parent/Guardian #1

Please place N/A if none.
Please enter your cell if none.

Parent/Guardian #2

Please place N/A if none.
Please enter your cell if none.

Emergency Contact

 Name and phone number(s) of person(s) other than yourself allowed to pick up your child. 

Child’s Medical Information Form 

The medical background of each camper is required as part of the camp’s registration process. The camp program director must be advised in writing of any condition that would limit the camper’s ability to participate in any program. 

If unsure, please estimate the closest date possible.
If unsure, please estimate the closest date possible.

*It is requested that parents/guardians administer any medication to the child before arriving to the Program. Program Staff will not administer any medication to a child. 

Allergies *
Does your child require an Epi-Pen? If yes, you must provide the camp with an Epi-Pen on the child’s first day at the camp. The Epi-Pen will be kept at the camp during your child’s enrollment. *


The Brookland-Lakeview 21st Century COLA Program does not discriminate on the basis of race, color, sex, handicap, religion or national origin. 

I understand and accept these guidelines. 

For the Summer Camp, transportation will not be provided by the Brookland-Lakeview 21st Century COLA Program to and from my child’s home. Bus transportation is provided for field trips only. Parents will drop-off and pick up their children. 

I give Brookland-Lakeview 21st Century COLA Program permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at the Brookland-Lakeview 21st Century COLA Program’s office and can be used for promotional purposes without notification. 

I give Brookland-Lakeview 21st Century COLA Program permission to transport my child off camp property for the purpose of field trips and/or medical care. I understand that a schedule of events will be available to me and that all events are subject to change due to weather and/or scheduling conflicts without notice. 

I authorize the Brookland-Lakeview 21st Century COLA Program Management to act as the agent of the parents in an emergency or to administer basic first aid for the health and welfare of the camper involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for person requesting exemption from medical treatment. 

By typing your name below, you agree to adhere to all Policies and Procedures set by the Brookland-Lakeview 21st Century COLA Program. 

Authorization and Waiver to Transport Child 

My child requires a booster seat: (all children under 8 years of age are required to be in a booster seat) *

I authorize Brookland-Lakeview Empowerment Center to transport my minor child in a car, van or bus driven by an individual authorized by Brookland-Lakeview Empowerment Center. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer. I understand participation in the identified event is not a requirement for participation in the program. 

I have read, understand, and discussed with my child: 

(1) My child will travel in a motor vehicle driven by an adult and my child is to wear their safety belt during travel; 

(2) My child is expected to listen to supervising staff/driver, respect staff and other children, the vehicles they ride in, and the other people they travel with during the trip; 

(3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and 

(4) My child is to remain in their seat and not be disruptive to the driver of the vehicle. 

Select Each Statement To Agree *


Your time and generosity help to increase access to healthy foods, senior citizen programs, job training and more for the families in the community.