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First name(Required)

Last name(Required)

Birthdate(Required)

Month

Day

Year

Single choice(Required)

Male

Female

Address(Required)

Phone(Required)

Email(Required)

Shirt Size(Required)

sm

med

lg

xl

2xl

kids sm

kids med

kids lg

PARENT/GARDIAN

Full name(Required)

Relationship to Camper(Required)

Phone(Required)

Email(Required)

Emergency Contact Information

Full Name(Required)

Relationship to Camper(Required)

Phone(Required)

Alernate Phone(Required)

MEDICAL INFORMATION

Please state any known medical conditions

Is the applicant currently taking any medication? (Required)

Yes

No

If yes, please list:

Does the applicant have any allergies? (Required)

Yes

No

If yes, please list:

Primary Care Physician: (Required)

Physician’s Phone Number: (Required)

Please select the activities the applicant is interested in (check all that apply): (Required)

Academic Support (Tutoring, STEM Workshops, Reading Circles)

Life Skills Workshops (Financial Literacy, Legal Rights Education, Emergency Preparedness)

Cultural and Recreational Activities (Cultural Days, Sports and Games, Arts and Crafts)

Health and Wellness (Mental Health Support, Healthy Living, Yoga and Meditation)

Community Engagement (Volunteer Opportunities, Guest Speakers, Parent Workshops)

Additional Information

Does the applicant have any dietary restrictions?(Required)

Yes

No

If yes, please describe:

Is there any additional information you would like us to know about the applicant?

Consent and Agreements

Parental Consent:

I, the undersigned, give permission for my child to participate in the IRTC Summer Camp activities.

Signature(Required)

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Medical Consent:

In the event of an emergency, I authorize the camp staff to seek medical treatment for my child.

Signature(Required)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Photo/Video Release:

grant permission for my child’s photos/videos to be used for promotional purposes by IRTC.

yes

no

Date and time

Month

Day

Year

Time

:HoursMinutes

Contact Us

323 East 53rd Street

Brooklyn, NY 11203

Connect with us

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Phone: (718) 940-7499

ccn846@yahoo.com

Registered Charity Number : 20-3419400

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