Leading Through Service - Helping Youth Build a Better Tomorrow

Leading Through Service - Helping Youth Build a Better Tomorrow Summer Camp Application

Sponsored by Ivy Community Center, Inc.
Camper's Name (First, Middle, Last Name)
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthdate

MonthDayYear
Age
Grade for 2026-27 School Year:
Male/Female
Youth T-shirt size
Name of Parent/Guardian 1
Daytime Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name of Parent/Guardian 2
Daytime Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
In Case of an Emergency, notify the following person(s) if the parent/guardian cannot be reached
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
In Case of an Emergency, notify the following person(s) if the parent/guardian cannot be reached
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Does your child have allergies or chronic illnesses? (fears, behaviors, etc.)
Does your child have any special needs we should be aware of? (fears, behaviors, etc.)
Explain
Does your child take any medication we should be aware of?
Camp Authorization
Photography Authorization
I grant permission for the Ivy Community Center, Inc. to use photographs, videos, or similar media of my child in connection with his/her participation in the Amazing Camp Adventure for purposes of publicity and/or publications solely for educational and promotional purposes.
Signature of Parent/Guardian
MonthDayYear
Authorization for Pickup
In the event that I cannot drop off or pick up my child for camp, I authorize the following persons to do so. Please advise the individual that a photo ID will be requested before the child is released. Also, please note that if a person’s name is not on this list, he/she will not be allowed to pick up your child from the camp.
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Parent/Guardian
X
Signature of Parent/Guardian
Date

MonthDayYear
Travel Authorization
I grant permission for my son/daughter to be transported to/from the Ivy Community Center for planned off-site field trips during the summer camp
Signature of Parent/Guardian
X
Signature of Parent/Guardian
Date

MonthDayYear
Camp Rules
1.Treat camp directors, counselors, volunteers, and other campers with respect. No name-calling or foul language.

2.Campers shall listen to and follow the camp personnel’s instructions.

3.Any electronic device brought to camp is the camper’s responsibility and can only be used during lunch break and at the end of camp.

4.Always remain with your assigned group during camp activities.

5.Campers shall not intentionally cause or attempt to cause physical or emotional harm to another camper or staff member.

6.Weapons or objects that might be considered a weapon, nor any illegal substances should be brought to the camp.

7.Campers shall treat all equipment, supplies, and facilities with care.
Camp Rules/Behavior Agreement
I, on behalf of myself and my minor child, agree to follow the rules of ICC Amazing Camp Adventure and its staff during my minor child’s participation in ICC Amazing Camp Adventure. I understand that any child exhibiting behavior that may cause harm to themselves, other campers, or camp staff will be asked to leave the program without a refund. These behaviors include, but are not limited to, hitting, kicking, biting, sexual harassment, and/or possessing weapons or illegal substances.
Signature of Parent/Guardian
X
Signature of Parent/Guardian
Date

MonthDayYear
Date
Contact Information

If you have any questions or concerns regarding this application, please contact Mrs. Patrice Nelson at (919)484-2223.
Registration Deadline - June 10, 2026

Payment may be made via PayPal using the link below, or by bank check or cash in person at the Ivy Community Center, 4222 Fayetteville Road, Durham, NC 27713, on Tuesdays between 11:30 a.m. and 2:00 p.m. Checks may also be mailed to the Ivy Community Center at the address listed above.
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Leading Through Service - Helping Youth Build a Better Tomorrow Summer Camp Application

Medical Information

Camp Authorization

Photography Authorization

Authorization for Pickup

Signature of Parent/Guardian

Travel Authorization

I grant permission for my son/daughter to be transported to/from the Ivy Community Center for planned off-site field trips during the summer camp

Signature of Parent/Guardian

Camp Rules

Camp Rules/Behavior Agreement

Signature of Parent/Guardian

Contact Information

Registration Deadline - June 10, 2026

My Products

Payment Methods