Mail this registration form for each camp participant to:

DMACC Perry Van Kirk Career Academy

1011 2nd Street

Perry, IA 50220

*You may also drop it off in person

Camper Information:


Last NameFirst NameDate of BirthGender


School NameGrade Completed

Parent/Guardian Information:


Last NameFirst NameE-Mail Address (please print)


Mailing AddressCityStateZip Code

Emergency Phone Numbers:


NameRelationshipPhone Number


NameRelationshipPhone Number

Camp Selection (circle one):

June 20th8:00AM-3:00PM

July 7th8:00AM-3:00PM

Note: Camp is limited to 20 campers per day. Campers will be accepted on a first-come, first-served basis. Once your camper is accepted, you will receive an additional letter from DMACC with an agenda and drop-off/pick-up instructions.

Lunch Preference (circle one):

DMACC provided lunch

My son/daughter will be bringing a sack lunch from home

Does this child have any health issues (example: allergies to anything (foods, bees, etc.) or is this child taking any medication? If yes, explain: (Note: DMACC staff does not administer or assist in the administration of any medications).


Clothing: Students will be participating in many hands-on learning activities and they should wear comfortable clothing that is safe to get dirty.

DMACC is an equal opportunity/affirmative action institution. If you have needs that require special assistance/accommodations, please call us at 515-428-8100.

Des Moines Area Community College shall not engage in or allow discrimination covered by law. This includes harassment based on race, color, national origin, creed, religion, gender, sex (including pregnancy and marital status), sexual orientation, gender identity, age, disability and genetic information. Veteran status in educational programs, activities, employment practices, or admission procedures is also included to the extent covered by law. Individuals who believe they have been discriminated against may file a complaint through the College Discrimination Complaint Procedure. Complaint forms may be obtained from the Campus Provost's office, the Academic Deans’ office, the Judicial Officer, or the EEO/AA Officer, Human Resources. For requests for accommodations, the Accommodation/Section 504/ASA Coordinator can be contacted at 515-964-6857. For Title IX questions and concerns contact 515-964-6850.

Agreement: I certify that I am the child’s legal guardian and I give him/her permission to participate in all scheduled activities during the DMACC Perry Van Kirk CSI/Criminal Justice camp. I also agree to hold DMACC, all staff participants, all facility host sites, and sponsors harmless for all personal injury that might result from participation in any part of this program.

DMACC has the right to dismiss campers who actions are determined to be detrimental to the camp. Campers’ parents/guardians are responsible for damages caused by campers. DMACC is not responsible for personal belongings lost, damaged or stolen at camp. Campers will have immediate care in case of illness or injury at the expense of parent/guardians medical plans.

(Please check one)


I hereby grant full and unconditional permission to Des Moines Area Community College to reproduce this student’s photographs and/or images in any and/or all publications and/or promotional materials.


Signature of parent or legal guardian of camper named aboveDate