Kamp Kuumba 2009

Enrollment Form

Please complete an application and submit $15.00 Registration Fee for each child that will be attending

Basic Information

Name of child:___________________________________________Sex:___M___F

Birthdate: ____________________________ Age: ______

Parents/Guardians Name:_____________________________________________

Home Address: __________________________________

  __________________________________

Home Telephone:_____________________________________________________

Work Telephone: (mother) _____________________(father) __________________

Emergency Contacts: 1) _________________________   Telephone:________________

                                 2)__________________________  Telephone:________________

Persons Authorized for Pick-Up______________________________________________

Home Address/ Phone of Parent…if different than above__________________________

Child Information

School:______________________________    Last Grade Completed:___________________

Food/Medication Allergies:______________________________________________________

Any other pertinent information:__________________________________________________

Would you be interested in enrolling your child in the Omega CDC After-School Program, scheduled to begin in August, 2009? Yes__________          No_________

This question is designed to gain information about community interest and is not official enrollment.

___________________________________________         __________________

Signature of Parent/Guardian                                                   Date

Kamp Kuumba 2009

Omega Community Development Corporation

1810 Harvard Blvd. , Dayton , OH 45406

Phone: (937)222-3447 E-mail: rachw727@yahoo.com