2017 Beat the Streets-Baltimore

STEM/Wrestling Camp
Camp Session 1: July 3, 2017 July 21, 2017
Camp Session 2: July 24, 2017 August 11, 2017
Youthworks Employment: June 26, 2017 July 28, 2017
July 10, 2017 August 11, 2017

Summer Camp Application

Applications are due by 5:00 pm on Friday, June 2, 2017.
Questions can be emailed to Lydell Henry, Camp Director, at info@btsbaltimore.org or 443-765-6748

Campers Full Name: First Name Last Name

Street Address:

City State / Province Postal / Zip Code Country

Birth Date: Month/Day/Year Current Age: Approximate Weight: (pounds)

Shirt Size: Youth MYouth LYouth XL SmallMedium LargeExtra Large

Gender: Male Female Phone Number: School:

E-mail Address where youd like to receive confirmation and information:

Camp Session camper is registering for: Middle School Camp, July 3 - 21, 2017 High School Camp, July 24 - August 11, 2017

Grade Entering Fall 2017: 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade
12th
Grade

Payment Information
Registration for the summer camp is $75 for students that attend Baltimore City Public Schools and $300 for
students that attend school in other districts. Payment can be made via online, check or money order. Due
date for payment is June 2, 2017. Online payments (paypal) or send payment by mail to BTS-Baltimore, 5026 Woods
Line Drive, Aberdeen, MD 21001. For more information, contact us at 443-765-6748.

Emergency and Medical Information

Please provide at least 2 emergency contacts. Please list other important emergency contacts, their relationship to
camper, best phone numbers or other contact information that will be helpful in an emergency.

1st Emergency Contact 2nd Emergency Contact

Name: Name:
Relationship: Relationship:
Daytime Phone Number: Daytime Phone Number:
Evening Phone Number (if different): Evening Phone Number (if different):

(CONTINUED)
 Summer camp Application
(CONTINUED)

Doctors Name or Medical Clinic:

Doctors Phone Number:

List any medical food allergies: (If none, enter none)

List any chronic illness and or physical limitaitons camp should know about: (If none, enter none)

List all current medications: (If none, enter none)

Is camper covered by medical insurance:* Yes No

Name of Insurance Company (enter none if no insurance):

Policy Number (enter none if no insurance):

What STEM discipline most interests you? If you had to do a research project for a science
Life Sciences(Biology, Chemistry, Biochemistry) fair, what would you do?
q Technology (Computer Science, Software/Video
Game Developer)
q Engineering (Electrical, Civil, Biomedical, Industrial)

Participation in the 2017 Morgan State University

Regional Science Fair is required for this program? Will
you commit to participating* Please list any student organizations you are currently a
YesNo member of:

Has your son/daughter been involved in any Beat the

Streets activities? Yes No
Liability Release
I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend the
Beat the Streets - Baltimore STEM/Wrestling Camp and consent to its Discipline Policy and also do hereby release Beat the Streets and Morgan State University from any and all
liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of Beat the Streets. I
am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give
permission to the physician selected by a representative of Beat the Streets to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the
person named above. I understand that Beat the Streets carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or
hospital arising from treatment of injury or illness. I furthermore understand Beat the Streets often takes photographs or videos of participants during its activities or events. I
grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of Beat the Streets or Morgan
State University. Beat the Streets will not identify me or my child by name, or release any other personal information without additional written permission from me.

By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.)*

Signature: Current Date:

Relationship to registered camper:

Strengthening Beat the Streets Programs

Parent Informed Consent Form (Active)

Please complete the following information and indicate whether or not your child can participate
in each of the following parts of the afterschool research study.

I, ____________________________, am the parent or guardian of __________________________,

(parent/guardian name) (childs name)
and I am 18 years old or older.

1. School behavior and achievement information

_____ I AGREE to allow Beat the Streets-Baltimore to collect my childs school grades, test
scores, attendance,
disciplinary records, and teachers report of classroom behavior.
_____ I DO NOT agree to allow Beat the Streets-Baltimore to collect my childs school grades,
test scores, attendance, and disciplinary records, and teachers report of classroom behavior.

2. Videotaping/photographs of afterschool program

_____ I AGREE to allow my child to be videotaped/photographed as he/she participates in the

afterschool program.
_____ I DO NOT want my child to be videotaped/photographed.

___________________________________
Child Name (Printed)

__________________________________________________
Location where your child attends the afterschool program

__________________________________________________
Name of your childs elementary/middle school
____________________________________ _____________________________
Parent/Guardian Signature Date

____________________________________
Parent/Guardian Name (printed)

Demographic Survey

1. Marital Status
What is your marital status?
Now married
Widowed
Divorced
Separated
Never married

2. Household Income
What is your total household income?
Less than $10,000
$10,000 to $29,999
$30,000 to $49,999
$50,000 to $75,000
$75,000 to $100,000

3. Ethnicity
Please specify your ethnicity.
Hispanic or Latino
Not Hispanic or Latino

4. Race
Please specify your race.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

5. Employment Status
Are you currently...?
Employed for wages
Self-employed
Out of work and looking for work
Out of work but not currently looking for work
A homemaker
A student
Retired
Unable to work