Summer Camp Registration 2026

Summer Academy Day Camp

*Summer camp is only for those who are 12 years and younger by the start of the selected camp session. Please only register those in *your household.
June 8- June 26 8am-3pmJuly 6- July 24 8am-3pm

Parent/Guardian Information
Parent/Guardian Information #1
Name*

First NameLast Name
Primary Number*

Area CodePhone Number
E-mail*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Work (please put N/A, if not applicable)*
Work Phone Number*

Area CodePhone Number
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
If none put N/A
Hours of Work*
ex: 7a-3p
Yes, Active MilitaryYes, Reserve MilitaryNo, none
Parent/Guardian Information #2 (If applicable, please fill out each line)
Name

First NameLast Name
Primary Number

Area CodePhone Number
E-mail
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Work (please put N/A, if not applicable)
Work Phone Number

Area CodePhone Number
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Hours of Work
ex: 7a-3p
Yes, Active MilitaryYes, Reserve MilitaryNo, none

Emergency Contact

CANNOT BE PARENT LISTED ABOVE
Emergency Contact's Name *

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Additional Emergency Contact's Name (CANNOT BE A PARENT) *Only use this section, if your children have separate emergency contacts

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Authorized Pick Ups
Authorized to Pick-Up*

Certification

Please read before signing
This organization is supported with Federal funding. According to Title 18, Section 1001 of the U.S. Code, it is a felony for any person to knowingly and willingly make false or fraudulent statement to any department of the United States Government. By signing this Document, I certify under penalty of perjury, that all the information on this application is correct to the best of my knowledge and belief, and I acknowledge that such information is subject to verification. I also acknowledge that my failure to provide necessary documents within a reasonable period of time or falsification of this information shall be grounds for my termination from the program. I authorize the release of said information to the City of St. Louis and state and federal agencies.
Parent/Guardian Print Name
Signature

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Date

MonthDayYear
Date

Camper Information
Student 1 Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Incoming Grade*
School Attending in the Fall*
MaleFemale
Student Race/Ethnicity*
Student t-shirt size
This child is in good health, is able to participate in group care, has no special health or medical requirements.This child is able to participate in group care but has special health or medical requiremens listed below.
Please describe any special needs or concerns regarding your child
Please list any known allergies
Please list any medications and reason? If they have an inhaler please provide an Asthma Action plan to Midtown.
YesNo

Van Transportation
YesNo

Van Transportation
Spots are limited to those living in 63110 and potentially some who live in 63104.
- Youth must be picked up from home.
- All van riders must be ready promptly when the van arrives
- Youth will be dropped off sometime approximately 30 minutes after camp session ends.
- Someone must be available at home to receive them when the van drops them off as the van driver cannot leave the van.
- If your child cannot come on a given day you must notify Midtown as soon as possible. Anyone who misses the van without notice to Midtown risks being dropped from the route.
- All van riders must remain seated, wear their seat belt, be kind and courteous, converse quietly, and follow all instructions from the driver.
What address should your children be dropped off and picked up?
I consent to the guidelines outlined for van transportation. I also agree to release, hold blameless, and exonerate Midtown Neighborhood Opportunities Corporation and or any agents acting on their behalf from any liability which may occur from the use of transportation services.

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Vaccination Records & Waivers
Please upload vaccination records for each child, ensuring they are clear. You can also drop them off prior to the first day of camp at Midtown. Failure to receive vaccine records by day 3 of camp, will result in your child being suspended from camp until records have been received*

Browse Files

Cancelof
Liability Waiver

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by undefined. I acknowledge that undefined will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event undefined is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize(s) any of the staff or employees to provide for, approve and authorize health care at hospital.
Hospital Preference*
Hospital Number*
Doctor's Name*
Doctor's Office Phone Number*
YesNo
Field Trip Waiver

I understand that although the students will be supervised by Midtown Neighborhood Opportunities Corporation’s staff, I do assume the risk in my student’s participation in field trips. I acknowledge that I will not seek to have Midtown Neighborhood Opportunities Corporation held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in any Midtown sponsored field trip. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student’s participation in the event. I hereby release and agree to hold harmless Midtown Neighborhood Opportunities Corporation, its officials, agents, and employees, from any claims arising out of my son’s/daughter’s participation in any Midtown-sponsored field trip.
YesNo
Signature*

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Joe & David's Pool Party Day Waiver

I acknowledge that my child/ren will be participating in an off-campus outing at one of Midtown's family donors' home for the day for a private pool party on June 11 and July 16. If I would like my child to not participate in this activity for the day, I will make sure that my child will be absent from camp on the dates listed.
Yes, I consent to allow my child/ren to participate at Joe & David's Pool Party.No, I do not consent to let my child participate at Joe & David's Pool Party and I will keep them home for the day.
Signature

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Waivers Continued
Late Fee Policy

In order to be fair to our participants and staff, Midtown Community Services has enacted a late pick-up policy.
Each time a participant is not picked by designated ending time, a $1.00 per minute fee will be charged. Registration for other programs will not be accepted until all outstanding late fees are paid. The late fee is due within three days. Payments can be made in person or online, an invoice will be sent.
Failure to pay late pick-up fees could result in your child’s suspension from the program.

*Note: Midtown Community Services shall make every reasonable effort to contact persons authorized by you to pick up your child. If we are unable to arrange pick-up within 30 minutes, we will request the assistance of the St. Louis Police Department.
YesNo
Photo Release

I hereby grant and authorize undefined the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications.

This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.
YesNo
Text and Email Notifications I give the afterschool staff permission to contact me through the Text Message software and email for updates regarding programming, time/date changes, upcoming events, etc.
YesNo
I am in agreement with the Late Fee policy, Photo Release, Text/Email Notifications Policies.*

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Emergency Protocols
In the event of an emergency situation, Midtown Community Services has outlined the below response plan. Please know that Midtown will make every attempt to notify you so it is vital that you keep your emergency contact information up-to-date. Keep this letter with you so that you will know how to contact us in the event of an emergency.

Evacuation / Relocation

1.       If the emergency is confined to the immediate area at Midtown e.g. fire, and the children cannot stay on the premises, the children will be taken to St. Cronan’s Catholic Church across the street from Midtown. The children and staff will remain at this location while you or your emergency contact is notified of the situation.

2.       If the emergency is more widespread and encompasses a larger area such as the neighborhood due to an environmental threat, e.g. flood, and the children cannot remain in the immediate area, they will be transported to City Greens Market at 4260 Manchester Ave, St. Louis, MO 63110.   The children and staff will remain at this location while you or your emergency contact is notified of the situation.

Notification

1.       Every effort will be made to contact you as soon as the children and staff are safe. We will contact your alternate emergency contact if we cannot reach you. Children will only be released to you or your alternate emergency contact during times of emergency.

2.       Midtown will not be open on days St. Louis Public School is not in session due to severe or winter weather.

Emergency Supplies

1.       Midtown will have emergency supplies on hand like blankets, food, flashlights.

PLEASE INTITAL BELOW THAT YOU HAVE READ AND UNDERSTAND MIDTOWN'S EMERGENCY PROTOCOLS.
Initials*

Participant Behavior Expectations
MIDTOWN PARTICIPANT BEHAVIOR CONTRACT

Parents/Guardians: Please take a moment to review with your camper(s) the following and agree that you have read below.

Participants will arrive and remain at Midtown with a positive attitude, open to meeting new people and trying new activities.

Participants will work with their Group Leaders towards creating an environment that is safe and welcoming to all participants.

Participants will be aware that disrespectful behavior includes, but is not limited to, hitting, punching, kicking, biting, spitting, swearing, lying, and refusing to listen to Midtown staff.

Participants understand that doing intentional harm or bullying toward another participant, either physically or emotionally is grounds for dismissal from Midtown.
Participants understand that although the participant may be able to solve some conflicts on their own, the Midtown staff is always ready to listen and assist if there is a problem.

Participants should understand that Midtown Staff need and want to help but can only do so if the participant is willing to share any concerns they are having with them.
Participants will remain with their group and partake in the activities as required.

Participants will use appropriate language and understand that the use of excessive, deliberate, profane language will not be accepted.

Participants will leave their cell phone and other electronic devices at home. Any outside items will be stored in the office. Participants should understand that if there is an emergency Midtown staff will be happy to allow them to use the phone and will pass on any urgent messages from home.

Participants will be respectful of the property and personal space of other participants and Midtown staff.
Participants will be respectful of Midtown buildings and any other location they might visit while attending Midtown.

Participants will not possess smoking materials, lighters, matches, illegal drugs, alcohol or weapons of any kind on Midtown property.

Behavior Management

For non-physically related offenses staff will use positive reinforcement to help participants adhere to this behavior contract. In case of continued behavior problems, the staff may implement the following consequences, depending on severity:
- Staff will redirect the participant to more appropriate behavior.
- Staff will remind the participant of the behavior guidelines and rules and be asked to reflect on how he/she can correct his behavior.
- A participant can lose out on special incentives, activities, or field trips.
- A participant may receive a necessary time out to calm themselves and correct his/her behavior.
- If a participant continues with inappropriate behavior, he/she will meet with the Youth Director to discuss the situation. At this time, a phone call to a parent or guardian will be made.
- After the 2nd incident following a phone call home participant will be suspended for 1 day of Midtown Youth Program.
- After the 3rd incident the participant will be suspended for 1 week of Midtown Youth Program following a conference with parents and the Youth Director. A Behavior Correction form will be completed.
- All other offenses following the 3rd offense will result in the participant being removed from Midtown Youth Program.
- In the case of a participant being physically violent (kicking, biting, punching, hitting, etc.):
1st Incident- Participant will need to be picked up from Midtown Youth Program early on the day of the offense and will automatically receive a 1-day suspension from Midtown Youth Program. Parent/ Guardian and participant will need to meet with the Youth Director

After the 2nd physical incident participant will be suspended from Midtown Youth Program for a week and will need to fill out a Behavior Correction Form prior to returning.

Following a 3rd occurrence the participant will be removed from Midtown for the remainder of Midtown Youth Program.
If there are any safety and/or behavior concerns with off-site field trips or activities, a child may not be able to attend the function. If this happens, the parent is responsible for finding alternate child care.

No refund will be given for days that participants miss due to suspension and/or removal from Midtown Youth Program.

To help us have a great Midtown Youth Program we ask if you have any suggestions on behavior management for your child.
YesNo
Parent Signature *

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Camp Payment

1 Camper$40.00

2 Campers$45.00

3 Campers$50.00

4 Campers$55.00

Enter coupon

Total $0.00

Credit Card

Submit Your Application

You will receive a copy of your application after pressing the submit button. If you do not please check with Midtown staff at 314-534-1180 because there is a large chance that your application was not received.
Should be Empty:

Summer Academy Day Camp

Parent/Guardian Information

Emergency Contact

Authorized Pick Ups

Family Information

Statistical Information and Income Self-Certification Form

FAMILY INCOME:

Certification

Income Documentation

Camper Information

Extra Camper Registration

Van Transportation

Van Transportation

Vaccination Records & Waivers

Joe & David's Pool Party Day Waiver

Waivers Continued

Emergency Protocols

Participant Behavior Expectations

Camp Payment

Credit Card

Submit Your Application