When Worlds Collide
by
F U T U RE
B as ke t b a l l | E d uc a ti o n | L e a d e r sh i p
1
W.W.C.
2017 Summer Camp
Program Application
1. CHOOSE WEEKS
• Circle the weeks you wish to attend. Please signature each week that confirms your child will be attending camp and the
parent/guardian understands and agrees with each policy and procedure.
Week 1: June 19-23 ______ Week 2: June 26-June 30_____ Week 3: July 3,6,7_____
Week 4: July 10-14 _____Week 5: July 17-21 _____Week 6: July 24-28 _____
Week 7: July 31-August 4 _____Week 8: August 7-11 _____Week 9: August 14-18______
2. CAMPER AND PRIMARY CONTACT INFORMATION
Name of 1st Camper: __________________________________ Date of Birth: ___________ Age (at the time of Camp): _______
Name you prefer to be called (if different): _________________________________________________
Name of School: _____________________________________________
Grade: _______
T-Shirt Size (circle one): Youth: XS SM MED LG or Adult: SM MED LG XL XXL XXXL
Name of 2nd Camper: __________________________________ Date of Birth: ___________ Age (at the time of Camp): _______
Name you prefer to be called (if different): _________________________________________________
Name of School: _____________________________________________
Grade: _______
T-Shirt Size (circle one): Youth: XS SM MED LG or Adult: SM MED LG XL XXL XXXL
Name of 3rd Camper: __________________________________ Date of Birth: ___________ Age (at the time of Camp): _______
Name you prefer to be called (if different): _________________________________________________
Name of School: _____________________________________________
Grade: _______
T-Shirt Size (circle one): Youth: XS SM MED LG or Adult: SM MED LG XL XXL XXXL
Name of Parent/Guardian/Primary Contact: _________________________________________________________________
Mailing Address: ___________________________________________________________________________
City: ______________________________ State: _______________________ Zip Code: ________________________
Home Phone: _______________________ Cell Phone: _____________________ Work Phone_____________________ Email
address you check frequently: ______________________________________________________
Best way to contact you? (circle one) Home Phone
Cell Phone
Email
What is the race/ethnicity of you/your camper?* __________________________________  Prefer not to say
*Knowing the demographic makeup of our campers/community can assist in grant writing, intentional outreach, and more -- please
respond if you feel comfortable.
3. Authorized Family/ Friend for Pick Up (please provide two additional people, different from the parent/guardian listed
above, who would be allowed to pick child up from camp)
First Contact’s Name: ______________________________________ Relationship: __________________________
2
Home Phone: _____ - ______ - ______
Work/Cell Phone: _____ -______ - ______ ext ______
Second Contact’s Name: ____________________________________ Relationship: __________________________
Home Phone: _____ - ______ - _______
Work/Cell Phone: _____ -______ - ______ ext ______
4. SAFETY INFORMATION (please list all known conditions so we can accommodate your camper’s needs)
Does your camper have any behavioral issues, or special needs the staff should know about?
5. Payment Info (Please Initial)
NO REFUNDS on any Payments. ________
Weekly Camp Payments are due on the Friday prior to the week camper attends. If any
Bi-Weekly, the first initial payments must be for 2 weeks. _____________
TRIP FEES: There will be 2 trips per week. The trip fee for entire summer will be $234.
You can pay the entire fee up front or you have the option of paying $26 weekly due at the same
time as tuition. ________________
6.Important
Information and Policies for W.W.C
We have partial day and Full day camp hours’ availability
Registration Fee: $40
Partial day hours consist of 8am – 3:30pm
Full Day hours consist of 7am- 5:30 pm
Additional half hour (6:30) available in the morning for $15 and (6pm) afternoon for $15.
Rates before March 1st
$95 for partial day
$105 for Full fay
Rates After March 1st
$105 partial day
$115 full day
Take advantage of discount!! Pay trip fee and first two weeks at time of registration and take advantage of discounted
Rate even after March 1st
Sibling Discount: First camper pays FULL PRICE second camper gets $10 DISCOUNT. Third camper gets $5
DISCOUNT
Late Fees: It will be a $5 LATE fee for each day payment is late and $3 late for each minute your child is picked up late.
Our discipline comes from a Martial Arts background and will consist of various exercises including : push ups, sit ups,
jumping jacks, iron chairs, frog leaps, and meditation.
Please Sign Confirming You Understand and Agree to All Policies _________________________
3
Parent Release Form for Media Recording
I, the undersigned, do hereby grant or deny permission to Future Hoopers / When Worlds Collide to use the
image of my child, _________________________________, as marked by my selection(s) below. Such use
includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or
video taken of my child for use in materials that include, but may not be limited to, printed materials such as
brochures and newsletters, videos, and digital images such as those on the Future Hoopers / When Worlds
Collide website.
Deny permission to use my child’s image at all.
☐
☐
Grant permission to use my child’s image in the following ways (mark all that apply):
☐
Limited usage: I want my child’s image used within the Future Hoopers / When Worlds Collide
setting only (not in the larger community).
☐
Limited usage: I want my child’s image used for educational materials only (not marketing). This
could be either within Future Hoopers / When Worlds Collide or in the larger community. One
example of this could be videos in parent education classes.
☐
Limited usage: I want my child’s image used on printed materials only (no digital or video use).
☐
Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video,
and digital media. I agree that these images may be used by Future Hoopers / When Worlds Collide
for a variety of purposes and that these images may be used without further notifying me. I do
understand that the child’s last name will not be used in conjunction with any video or digital
images.
Parent/Guardian signature
Date
Please make a copy of this form for your own records and return the original to:
Andre Wilburn
Co Owner/Director
Future Hoopers / When Worlds Collide
If you have questions, contact Andre Wilburn at 3025135423.
4