Summer Program Registration

The 2022 Summer Academic Program dates are June 6th through July 29th.

The program runs from 7:30 AM – 6:00 PM Monday through Friday.

Please visit our FAQ page for additional details.

2022 SUMMER ACADEMIC PROGRAM REGISTRATION

Here is a full list of all the sites available in our Summer Academic Program by location and grade. Students may only enroll in ONE site. Spots at each site are limited to first come first serve. We will be updating this list as sites fill up:

Friendship Baptist Church: Grades K-5 — 3530 Chelsea
Macedonia Baptist Church: Grades K-5 — 1700 Linwood
Palestine Missionary Baptist Church: Grades 1-5 — 3619 E. 35th Street

We cannot accept applications for child(ren) born after August 31, 2017.

Please complete the form below to register your child(ren) in the summer program — you may enroll multiple children with one application. Fields labeled with an * are required.

How many children will you be enrolling in our program?*

Please enter a number from 1 to 10.

Is your child (or children) at least 5 years old? NOTE: We cannot accept applications for children born after 08/31/2017.*

Upper Room cannot accept applications for children under the age of 5. Thank you for your interest.

Student Info

Student's Name	Date of Birth	Upcoming Grade Level	Actions

There are no Students.

Parent / Guardian’s Name*

Parent / Guardian’s Email Address*

(for enrollment confirmation)

Parent / Guardian Mobile Number*

Student's Physical Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact*

Relationship to Student*

Phone Number*

Summer Academic Program Rules and Regulations:

ATTENDANCE: Attendance will be taken each morning. The program is academically designed to discourage "summer learning loss," therefore, a pattern of consistency in attendance is encouraged.
TARDINESS: All students are expected to be in their classrooms when academic instruction begins. Children arriving after 8:15 am will be counted as tardy, three (3) tardies will equal one (1) absence.
LEAVING THE BUILDING: Students are not allowed to leave the building unless they are leaving the school grounds with their parents for the day.
SPECIAL SERVICES: Parents are encouraged to contact the program in the event their student(s) require special accommodations. A determination can be made on how best to support the student(s).
CITIZENSHIP: Students are expected to maintain a wholesome attitude toward learning and to display the utmost respect for the program, staff, environment and one another. The program has zero tolerance for bullying. Any child engaged in this behavior is subject to disciplinary action, including expulsion.
DRESS CODE: Students are expected to dress in the same manner as acceptable during the regular school year.
RULES & REGULATIONS: Students are expected to abide by all the rules and regulations established by the program's code of conduct. Failure to do so will result in disciplinary action.

I attest that my son/daughter:

Has all the necessary documents, including, but not limited to, birth certificate or other proof of parent/guardianship, immunization records and proof of residency, and are on file with the district/school.
Is eligible for summer school and is not currently serving on a long-term suspension or expulsion from any in-state or out-of-state district/school.
Has not been convicted or charged with any of the following crimes: first or second-degree murder; first-degree assault; forcible rape or sodomy; first-degree robbery; distribution of drugs to a minor; first-degree arson; or a Class A felony kidnapping.
Has not attended another summer school program offered by a public school district and/or charter prior to enrolling in the Upper Room Summer Academic Program.

Hidden

Consent*

I agree that my student will be placed in class(es) according to his/her current school's recommendation. I give my consent for Upper Room Summer Academic Program to request my child(ren)'s records from any current or previous district/school attended. I understand that if any of the above information is found to be false that my child(ren) will be removed from Upper Room Summer Academic Program.

Program Rules & Regulations Consent*

I understand and accept the Upper Room Summer Academic Program Rules and Regulations.

Field Trip Consent*

I give permission for my child(ren) to attend summer program field trips from June 6, 2022 to July 29, 2022. I also give permission for my child(ren) to receive medical attention in case of an emergency.

Photo Consent?*

I hereby authorize Upper Room Summer Academic Program to publish the photographs of my children, and our names, for use in Upper Room Summer Academic Program's printed publications, website, and social media profiles. I acknowledge that since participation in publications and websites produced by Upper Room Summer Academic Program is voluntary, neither the minor children nor I will receive financial compensation.

Where did you hear about Upper Room Summer Academic Program?

Questions / Comments

The 2022 Summer Academic Program dates are June 6th through July 29th.

The program runs from 7:30 AM – 6:00 PM Monday through Friday.

2022 SUMMER ACADEMIC PROGRAM REGISTRATION

We cannot accept applications for child(ren) born after August 31, 2017.

Please complete the form below to register your child(ren) in the summer program — you may enroll multiple children with one application. Fields labeled with an * are required.

Summer Academic Program Rules and Regulations:

I attest that my son/daughter:

VOLUNTEER

JOIN OUR TEAM

DONATE

Summer Program Registration

The 2022 Summer Academic Program dates are June 6th through July 29th. The program runs from 7:30 AM – 6:00 PM Monday through Friday.

2022 SUMMER ACADEMIC PROGRAM REGISTRATION

We cannot accept applications for child(ren) born after August 31, 2017.

Please complete the form below to register your child(ren) in the summer program — you may enroll multiple children with one application. Fields labeled with an * are required.

Summer Academic Program Rules and Regulations:

I attest that my son/daughter:

VOLUNTEER

JOIN OUR TEAM

DONATE

The 2022 Summer Academic Program dates are June 6th through July 29th.

The program runs from 7:30 AM – 6:00 PM Monday through Friday.