See instructions in Chinese / 於填寫資料之前，請詳閲中文指引

Thank you for using our online application form for

Cameron House's Summer Adventures 2026

2026 暑期歷程活動

Please review all of the following information before beginning.

ONLINE FORM INSTRUCTIONS

This form will only accept English responses. Chinese translations are provided for reference only.
Gather these items before starting this form:

Your child's SFUSD HO# and birthdate; priority enrollment is for San Francisco public school students
Your family's annual income, which can be found on your tax form; the funding we receive to provide this program is sometimes based on the family income level of our students. Your family's income level will not affect enrollment into our program and will be kept private
List of any food or medication allergies; knowledge of child's IEP or 504 plan
List of parent/legal guardian/emergency contact names and their phone numbers

If you need to take a break or need to get more information before you can finish, please use the "Save Your Progress" feature and come back at a later time to complete your child's registration. Saving your progress will require an e-mail address and a password of your choosing.
After submission, a staff will review the application and confirm if your child has been accepted into the program. An acceptance email will contain further instructions to complete your child's registration.

PROGRAM

Summer Adventures is ready to engage your child in literacy and science, field trips, Chinese heritage, and just a whole lot of fun with old and new friends! Thanks to the Department of Children, Youth and Their Families (DCYF) and our dedicated alumni, we offer this 8-week program to San Francisco students!

Cameron House's Heritage School is exempt from child care licensure. Attendance does not satisfy California's compulsory education requirements pursuant to Section 48200. (Added by Stats. 2010, Ch. 286, Sec. 1. (SB 1116) Effective September 24, 2010.)

LOCATION

Cameron House is located at 920 Sacramento Street, San Francisco, CA 94108

ENROLLMENT

Open to SFUSD students who are rising 1st through 8th graders in Fall 2026. Unfortunately, we are not enrolling rising kindergarten students.

PROGRAM DATES, TIMES AND FEES

June 15th 2026 to August 7th 2026, Monday through Friday, 9:30 AM - 4:30 PM

Early Drop Off: 8:30 AM- 9:30 AM

Extended Care: 4:30 PM - 5:30 PM

All students are expected to attend all 8 weeks, each day, until 4:30 PM.

For students enrolled in extended care, there is a late fee of $2 per minute (after 5:30 pm).

Holiday Closures (two days):

Friday, June 19th in observance of Juneteenth
Friday, July 3rd for Independence Day

Total Fee for 8 weeks is $1500

Refund requests must be sent in writing to <ymadmin@cameronhouse.org>:

A fee of $45.00 will be charged if program participation is cancelled on or before June 12, 2026
If student withdraws from program after June 12, 2026, $45.00 cancellation fee will be deducted and only 50% of fee will be refunded.

Attendance Expectations:

Elementary school-aged students are expected to attend full-time, 5 days a week until 4:00 PM.
More than 3 unexcused absences may result in being dropped from the program.

請詳細閱讀以下資料

填寫申請表格須知

此申請表格內容以英文作準，中文翻譯只作參考
填寫申請表格時請備有填表須知

學生的學生證號碼及出生日期（三藩市校區學生有優先錄取資格）
學生家庭全年總收入，可以根據學生家長報税表資料填報。活動資助機構以各家庭平均總收入決定資助金額, 閣下資料將會保密。
詳列學生有關藥物及食物敏感
詳列學生家長/監護人/緊急聯絡人姓名及電話號碼

假如閣下需要停頓休息或搜集相關資料，請按「Save Your Progress」然後可以再進行填報程序。此行動需要閣下的電郵地址及密碼
申請表被提交後，工作人員將會審核閣下小孩是否被接納參與此項活動。若被接納，閣下將會收到電郵通知進一步的登記程序

活動簡介

暑期歷程已準備就緒，為要聯繫閣下小孩參與中國文化課程、英文閲讀、數學、旅行及享受與新知舊雨一起渡過怏樂的時光。承蒙兒童及青少年家庭服務部及熱心捐獻的金美倫之友慷慨贊助，我們得以為三藩市校區及社區低收入和新移民家庭提供為期八週的暑期活動。

金美倫堂傳承學校無需持有孩童護理牌照，也無須遵行加州強制教育條例

條文見於Section 48200. (Added by Stats. 2010, Ch. 286, Sec. 1. (SB 1116) Effective September 24, 2010.)

活動地點

金美倫堂位於（920 Sacramento Street, San Francisco, CA 94108)

報名資格

活動開放予三藩市校區將要在今年秋季晉升一年級至八年級的學生報名，抱歉未能接受準備開始入讀幼稚園的小朋友報名。

活動日期、時間及費用

2026年6月15日至 2026年8月7日，週一至週五，上午 9:30－下午 4:30
提早到校：上午 8:30－上午 9:30
延長照顧：下午 4:30－下午 5:30

所有學生皆須於為期 8 週的課程期間，每週一至週五每天全程出席，並須留至下午 4:30。

費用八週共$1,500 元

每位參與學生必須每天出席至下午4:30，為期八週的活動假期共2天

6月19日（星期五）種族共融日
7月3月（星期五）獨立日

*收費一律同一價錢，無論學生何時開始參加課後班

退費要求必須電郵至：<ymadmin@cameronhouse.org>

如於 2026年6月12日或之前取消參加本計畫，將收取 45.00 美元 手續費。
如學生於 2026年6月12日 之後退出本計畫，將先扣除 45.00 美元 手續費，並僅退還已繳費用的 50%。

出席要求

所有學生必須每天出席每週5天活動（上午8:30-下午4:30）
若是出現多過3次無故缺席，可能將會被取消參與活動資格

I have read and understand the instructions and information listed above. / 本人已詳閲並明白以上指引及資料

Yes / 是的

Page 2 of 7

ENROLLMENT INFORMATION / 報名資料

Minor's First Name / 學生名字

Minor's Last Name / 學生姓氏

Grade in Fall 2026 / 2026年秋季入讀年級

DROP-OFF/PICK-UP INFORMATION / 接送孩子方式詳情

Minor Release Consent / 接送學生同意書

Estimated Pick-Up Time / 估計接回家時間

Picked Up By: Primary Name / 首要接學生人仕

Primary Pick-Up Relation to Minor / 關係

Primary Pick-Up Phone Number / 電話號碼

Picked Up By: Alternate / 次要接學生回家人仕

Alt. Pick-Up Relation to Minor / 關係

Alternate Pick-Up Phone Number / 電話號碼

Additional Pick-Up Information / 其它接學生回家資料

Page 3 of 7

MINOR GENERAL INFORMATION / 學生資料

Minor's Name / 學生的姓名

Middle Name/Initial (optional) / 中間名字

Home Phone / 家庭電話

Minor's Cell Phone (if available) / 手機

Minor's Email / 電郵地址

Gender Preference / 個人選擇

Birthdate / 出生日期

MM/DD/YYYY

T-Shirt Size / T 恤尺寸

SCHOOL

My child attends a school that is / 我的小孩入讀:

part of the San Francisco Unified School District (SFUSD) / 三藩市校區其中一所學校part of a different school district / 其它校區其中一所學校

SFUSD School / 學校

School Name / 學校

SFUSD HO# / 校區學生證號碼

ADDRESS / 居住地址

When inputting the address, please do not type Ave., St., etc. into the "Primary Street Name & Number" field. We request that you use the "Street Type" field to complete your address.
請填寫居住地址方式如以下舉例.

For example, if you live at 920 Sacramento St., you would:

- Type "920 Sacramento" in the Primary Street Name & Number field

- Select "St" in the Street Type field

Primary Street Name & Number / 門牌號碼及街名

Example: 920 Sacramento

Street Type

Other Street Type

Apartment #

Primary City / 城市

Primary State/Province / 州名

Primary Zip/Postal Code / 郵區號碼

DEMOGRAPHIC INFORMATION / 學生家庭背境資料

Because our funder requires us to collect some specific demographic information of our program participants and their families, please answer the following questions.
請回答以下問題為作資助機構相關家庭背境的資料統計

Please select the option that best represents your child's race / 學生種族，請選擇一項:

Please select the option that best represents your child's ethnicity / 學生種族，請選擇一項:

Please use this space to specify your child's race/ethnicity:

Please select the option that best describes your child's housing status. / 居住狀況, 請選擇一項

Please select the option that best represents your child's home language. / 在家中常使用的語言

Please specify your child's home language.

Please select the number of people in your family. A family is defined as all persons living in the same household who are related by birth, adoption, marriage, or domestic partnership. / 同住家人數目

Please select the income range that best fits your family's annual income / 家庭全年總收入.

Page 4 of 7

MINOR'S MEDICAL/EDUCATIONAL HISTORY / 未成年人仕醫療/教育紀錄

Has Minor received all required childhood immunizations /未成年人仕是否已接種各種兒童必須注射的預疫苗?

Yes / 是 No / 不是

Is Minor fully vaccinated for COVID-19 /未成年人仕是否已經完成接種預防新冠肺炎疫苗?

Yes / 是 No / 不是Minor is considered fully vaccinated 2 weeks after final dose in primary series (Pfizer or Moderna), OR 2 weeks after 1st dose (Johnson & Johnson). *完成接種是指未成年人仕已經接受最後一劑注射超過兩週（Pfizer/Moderna) 或（Johnson & Johnson) 超過兩週

Any student in our program who is feeling under the weather must stay at home for two to three days or until symptom-free. It’s important that everyone continues to practice safe and healthy habits to prevent spread of illness.

任何學生如有不適，請留在家中兩至三天或直至疾病痊癒。大家必須注意健康安全，這是對防止疾病抗散十分重要的一環。

Please list the name, dosage and purpose of medications currently being taken by Minor, as well as any other medical information that would be helpful in our work with your Minor. If none, please enter "None". / 請詳細列明未成年人仕需要服用藥物名稱、劑量及醫療用途，並同時列明未成年人仕其它醫療資料，以便不時之需。如沒有，請填寫 None。

Please describe any other special considerations regarding Minor, including all allergies, dietary restrictions, activity limitations, behavioral issues, recent trauma, or any other concerns. If none, please enter "None". / 請詳細列明未成年人仕其它特別需要，例如敏感、食物特殊反應，行動上的不便及限制、行為問題及其它必須關注的狀況。如沒有，請填寫 None。

We want to partner with you to provide the best experience for your child. To help us better understand your child’s needs, please tell us if they have a 504 plan and/or an Individualized Education Program (IEP). If applicable, one of our staff will be reaching out to you soon to discuss how to partner in support of your child. Check all that apply: / 我們盼望能夠與閣下合作，為閣下小孩提供是最佳美的經歷，為了讓我們更加理解閣下小孩需要，請告知我們閣下小孩是否正在參與504計劃或個別教育計劃（IEP)。若然，我們的工作人員將會與閣下商討，並為閣下小孩提供適當的支援。請選擇以下一項：

504 Plan / 504計劃IEP Neither / 兩樣都沒有

Page 5 of 7

PRIMARY PARENT/ LEGAL GUARDIAN INFORMATION / 家長及合法監護人

Parent/Guardian 1 First Name / 家長名字

Parent/Guardian 1 Last Name / 家長姓氏

Parent/Guardian 1 Primary Phone / 主要聯絡電話號碼

Parent / Guardian 1 Primary Phone Type

Parent/Guardian 1 Alternate Phone / 次要聯絡電話號碼

Parent / Guardian 1 Alternate Phone Type

Please select a different value than "Parent/Guardian 1 Primary Phone Type".

Parent/Guardian 1 E-mail / 電郵地址

A confirmation e-mail will be sent to this e-mail address / 所有電郵通訊將會傳送此地址

Use a different address than listed for child / 家長其它居住地址.

Yes / 是的

When inputting the address, please do not type Ave., St., etc. into the "Primary Street Name & Number" field. We request that you use the "Street Type" field to complete your address.
請填寫居住地址方式如以下舉例

For example, if you live at 920 Sacramento St., you would:

- Type "920 Sacramento" in the Primary Street Name & Number field

- Select "St" in the Street Type field

Street Name & Number / 門牌號碼及街名

Example: 920 Sacramento

Street Type

Other Street Type

Apartment #

City / 城市

State/Province / 州名

Zip/Postal Code / 郵區號碼

SECONDARY PARENT/LEGAL GUARDIAN INFORMATION / 其它家長及合法監護人

Parent/Guardian 2 First Name / 家長名字

Parent/Guardian 2 Last Name / 家長姓氏

Parent/Guardian 2 Primary Phone / 主要聯絡電話號碼

Parent / Guardian 2 Primary Phone Type

Parent/Guardian 2 Alternate Phone / 次要聯絡電話號碼

Parent / Guardian 2 Alternate Phone Type

Please select a different value than "Parent/Guardian 2 Primary Phone Type"

Parent/Guardian 2 E-mail / 電郵地址

Use a different address than listed for child / 家長其它居住地址.

Yes / 是的

When inputting the address, please do not type Ave., St., etc. into the "Primary Street Name & Number" field. We request that you use the "Street Type" field to complete your address.
請填寫居住地址方式如以下舉例

For example, if you live at 920 Sacramento St., you would:

- Type "920 Sacramento" in the Primary Street Name & Number field

- Select "St" in the Street Type field

Street Name & Number / 門牌號碼及街名

Example: 920 Sacramento

Street Type

Other Street Type

Apartment #

City / 城市

State/Province / 州名

Zip/Postal Code / 郵區號碼

Page 6 of 7

EMERGENCY CONTACT / 緊急聯繫人

The Emergency Contact must be at least 18 years of age, and someone other than the parent(s)/legal guardian(s) listed on the previous page. The role of the Emergency Contact is as follows:

1) Next person to contact in the event of an emergency or disaster when the parent/guardian cannot be reached

2) Pre-approved person(s) to whom Minor will be released in an emergency or disaster situation

It is Cameron House's policy that minors will not be released to the care of another minor in an emergency or disaster situation.

緊急聯繫人必須年滿 18 歲，並且是上述學生家長/合法監護人以外的人仕。緊急聯絡人是：

1) 在無法聯絡到家長/監護人的緊急或災難情況下，必須要聯絡的人仕

2) 在緊急或災難情況下，接走學生的人仕

金美倫堂的政策不允許在緊急情況或災難情況下將未成年人交給其他未成年人照顧。

Emergency Contact First Name / 緊急聯絡人名字

Emergency Contact Last Name /緊急聯絡人姓氏

Emergency Contact Relationship to Minor / 與學生關係

Emergency Contact Email / 電郵地址

Emergency Contact Primary Phone / 主要聯絡電話號碼（包括地區號碼及請選擇電話類別）

Emergency Contact Primary Phone Type

Emergency Contact Alternate Phone / 次要聯絡電話號碼（包括地區號碼及請選擇電話類別）

Emergency Contact Alternate Phone Type

Preferred Hospital: Please list the preferred hospital for your child in the event of a medical emergency. Sometimes emergency personnel asks for a preferred hospital. If no preference is listed, emergency personnel may decide. / 首選醫院：請列出您的未成年學生的首選醫院, 如果發生醫療緊急情況, 緊急護理人員需要知道學生首選醫院。否則，緊急護理人員可能会自行決定。

DISASTER/EMERGENCY RESPONSE POLICY / 緊急或災難情況處理程序

In the event of an emergency or disaster during program hours, Cameron House will hold your minor at either:

1) Cameron House (920 Sacramento Street)

2) Presbyterian Church in Chinatown (925 Stockton Street)

3) Other locations that are deemed safest based on staff's judgment of physical surroundings, ability and safety to travel, and other conditions.

The minor will be released only to the parent/legal guardian or designated emergency contact as listed in this registration form. Photo identification will be required.

如果在暑期班期間發生緊急或災難情況，金美倫堂會將您的孩子安全送到以下其中一個地點：

1) 金美倫堂 (920 Sacramento 街)

2) 三藩市中華基督教長老會 (925 Stockton 街)

3) 根據工作人員對周圍環境、出行能力、安全、以及當時條件狀況判斷後，確定最安全的其它地點。

在此種情況下，您的孩子只會被轉送給本註冊表中列明的家長/合法監護人或指定的緊急聯絡人。此人必須出示有效照片身份證明。

I have read and agree to Cameron House's Disaster/Emergency Response Policy / 本人已詳閲並同意金美倫堂災難緊急應變守則。.

Page 7 of 7

BILLING INFORMATION / 付款人資料

First Name / 名字

Last Name / 姓氏

Email / 電郵地址

Phone / 電話號碼

BILLING ADDRESS / 付款人地址

Billing Street / 街名

Billing City / 城市

Billing State / 州名

Billing Zip / 郵區號碼

Billing Country / 國家

I understand that payment (credit card, check or cash) is required to complete enrollment / 申請入學表格必須填寫付款方式, 並於報名時即時付交費用。.

PROGRAM PAYMENT / 活動費用

If you need Financial-Aid, please contact Cameron House staff and submit valid documentation for verification. Upon review, we will assist you in applying for the low-income fee adjustment.

If you have any questions, please call (415) 781-0401 ext. 112 or email ymadmin@cameronhouse.org.

如您需要經濟援助，請與金美倫堂工作人員聯繫，並提交相關證明文件。經核實後，我們將協助您申請低收入減免費用。

如有任何疑問，請致電 (415) 781-0401 分機 112，或電郵至 ymadmin@cameronhouse.org 與我們聯絡。

Payment (cash, check, or credit card) is required to complete enrollment.

付款時必須連同埴寫妥當的報名表。

Total Program Fee / 活動費用數目

$

.00

Please select your payment plan:

I will pay the full fee todayI will pay 50% today and 50% by July 11, 2025

Payment Due

$

.00

Method of Payment / 付款方式:

Credit Card / 信用咭Check / 支票Cash / 現金

Please verify that the "Payment Due" is correct before submitting your credit card information.

呈交信用咭之前請準確肯定：

Checks can be made payable to DONALDINA CAMERON HOUSE with child’s name, grade, and “Summer Adventures 2026” indicated on check. 付款時必須連同埴寫妥當的報名表。支票抬頭：DONALDINA CAMERON HOUSE 並備註學生姓名、年級及“Summer Adventures 2026”於支票。.

Bring or mail check payment to: 請親身送到金美倫堂或郵寄至以下地址:

Donaldina Cameron House

920 Sacramento Street

San Francisco, CA 94108

Attention: Youth Enrollment

HOURS: 10:00 AM - 6:00 PM

Bring cash payment to: 若以現金支付，請親身送到金美倫堂

Donaldina Cameron House

920 Sacramento Street

San Francisco, CA 94108

Attention: Youth Enrollment

HOURS: 10:00 AM - 6:00 PM

CREDIT CARD INFORMATION / 信用咭資料

Credit Card Number / 信用咭號碼

Credit Card Expiration Month / 有效月份

Please use format MM (eg. 01 for January)

Credit Card Expiration Year / 有效年份

Please use format YYYY (eg. 2026)

Credit Card CVV/Security Code / 安全號碼

REVIEW & CONFIRMATION / 審核及確定

By submitting this registration form, I willingly acknowledge that all information entered regarding the minor, the minor's relationships, and the minor's family to be accurate / 本人提交此報名表並確認所有填報資料真實無誤，包括關於本人未成年子女，和本人及家人關係

Click the "Review" button to confirm or edit your responses. At the bottom of the "Review" page, there are 3 buttons:

CONFIRM - To finalize your responses, you MUST click the CONFIRM button. Please do not hit the "Back" or "Refresh" button after hitting confirm. The form can sometimes take a minute to process, so thank you in advance for your patience.

EDIT - To make any changes to your response, please click the EDIT button.

PRINT - If you would like a printed copy of this form, you must click the PRINT button before clicking the CONFIRM button.

NOTE: After review and submission, if you experience a processing error, please save your progress if possible. Staff will look into the error and follow up with you about the issue. Please DO NOT submit the form multiple times.

若需確定或修改，請按”Review”，可選其中一項：

確定：若需確定完成報名，請按”CONFIRM”，並請耐心等候，不要再按鍵盤，可能需時數分鐘

修改：若需修改，請按”EDIT”

打印：若需打印，請於按確定”CONFIRM”前按”PRINT”

備注：

若提交報名表後出現不明狀況，請儲存報名表內容，金美倫堂職員將會作進一步調查，敬請不要多次呈交報名表。

FORMULAS AND HIDDEN FIELDS

Conversion Source

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