Camp Registration | Pickney Time Summer Camp

Camper Information

Tell us about the child attending camp.

Camper Full Name *

Date of Birth *

Grade Entering Fall *

School Attending

Age Group *

T-Shirt Size

Primary contact for all camp communication.

Primary Parent/Guardian Name *

Relationship to Camper *

Phone Number *

Email Address *

Home Address *

Second Parent/Guardian (optional)

People we can reach beyond the parent/guardian, and everyone allowed to pick up your camper.

Emergency Contact 1 — Name & Phone *

Emergency Contact 2 — Name & Phone

Authorized Pickup List * List every adult allowed to pick up your camper. If someone should NOT be allowed pickup, note that here too.

This helps our staff keep your camper safe every day.

Allergies (food, insect, medication)

Current Medications & Medical Conditions

Physician Name & Phone

Health Insurance Provider & Policy #

Swimming Ability

Dietary Restrictions

Select every week your camper will attend. (Exact 2026 dates will be confirmed once we lock the calendar to Chicago Public Schools' summer break.)

Extended Care

Interested in Sliding-Scale/Scholarship Pricing?

Purely optional — helps our Culture Bearers understand who's in the room.

Cultural/Heritage Background

Home Language

Has your camper played any Jamaican games before?

Please read and check each box.

Photo/media release: I allow photos/videos of my camper to be used on Pickney Time's website and social channels.

Sunscreen/insect repellent: I authorize staff to apply sunscreen/repellent I provide as needed.

Parent/Guardian Signature (type full name) *

Date *