Dental Health Summer Camp Lee

Monday, June 15, 2026 at 9:00 AM until Wednesday, June 17, 2026 at 2:30 PMEastern Daylight Time UTC -04:00

Lee County – Keller Health Sciences Building Room 223
, NC
United States

The CCCC Dental Health Camp will involve discussions about oral hygiene and
hands-on activities that will engage students with skills typically provided by both
dental assistants and dental hygienists in dental practice.

Students should be prepared to encounter activities that may be a little messy so
casual clothing that could be potentially stained should be worn.

The CCCC Dental Programs encourage students to be excited to participate and learn
more about the importance of oral health and consider dentistry as a potential career
in the future.

Student Information

Student Email Address (if available)

First Name

Middle Name

Last Name

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Parent/Guardian Information

Full Name of Person Completing This Form

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent 1 Email

Parent 1 Contact (mobile) Phone Number

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent 2 Email

Parent 2 Contact (mobile) Phone Number

Parental Waiver and Release

As the parent or legal guardian (hereafter, "I" or "me") of the child(ren) named below (collectively, "we" or "us"), I hereby express my willingness and desire for my child to participate in the event named below ("Event") sponsored or otherwise overseen by Central Carolina Community College ("CCCC") and taking place on the premises named below ("Premises"). In consideration of being permitted by CCCC to allow my child to participate in the Event and to access the Premises, I agree to all the Terms and Conditions set forth in this Waiver and Release.

Terms and Conditions

We shall comply with the Policies and Procedures of CCCC as found at https://www.cccc.edu/about/policies-procedures/ and any other policies, procedures, rules, or instructions, whether verbal or written, as provided to us by CCCC personnel. I understand that it is my responsibility to read, understand, and ensure that we comply with these Policies and Procedures. While we will follow all Policies and Procedures, I acknowledge that specific attention must be paid to the following and could result in the involvement of law enforcement: a. Weapons, including but not limited to knives, firearms, and tasers, are prohibited on the CCCC campus; b. Illegal drugs, illicit substances, alcohol, and smoking are prohibited on the CCCC campus; and c. Network and internet use shall not include anything illegal, obscene, or otherwise in violation of the Policies and Procedures.
We shall comply with any security signs, postings, or instructions given to us by CCCC personnel during the course of the Event, including time spent on the Premises in connection with the Event, whether before, during, or after the Event. We shall only access parts of the Premises as authorized by CCCC personnel.
If provided, we shall wear or otherwise remain in possession of a visitor badge or other form of identification associated with participation in the Event.
I understand that failure to comply with these Terms and Conditions may result in my or my child's removal from the Premises, the Event, or both.
I AM AWARE AND UNDERSTAND THAT ACCESSING THE PREMISES AND ENGAGING IN THE EVENT MAY INVOLVE THE RISK OF SERIOUS INJURY, ILLNESS, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE. I ACKNOWLEDGE THAT ANY INJURIES THAT WE SUSTAIN MAY RESULT FROM OR BE COMPOUNDED BY THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF CCCC AND ITS PERSONNEL, INCLUDING NEGLIGENT EMERGENCY RESPONSE OR RESCUE OPERATIONS OF CCCC AND ITS PERSONNEL. NOTWITHSTANDING THE RISK, I ACKNOWLEDGE THAT WE ARE VOLUNTARILY ACCESSING THE PREMISES AND ENGAGING IN THE EVENT WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY, ILLNESS, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING THEREFROM, WHETHER CAUSED BY THE ORDINARY NEGLIGENCE OF CCCC OR ITS PERSONNEL OR OTHERWISE.

I hereby expressly waive and release any and all claims, now known or hereafter known, against CCCC, and its officers, directors, managers, employees, agents, affiliates, successors, and assigns (collectively, "Releasees"), on account of injury, illness, disability, death, or property damage arising out of or attributable to our participation in the Event, whether arising out of the ordinary negligence of CCCC or any Releasees or otherwise. I covenant not to make or bring any such claim against CCCC or any other Releasee, and forever release and discharge CCCC and all other Releasees from liability under such claims. If any term or provision of this Waiver and Release is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision or invalidate or render unenforceable such term or provision in any other jurisdiction. This Waiver and Release is binding on and shall inure to the benefit of CCCC and me and our respective successors and assigns. All matters arising out of or relating to this Waiver and Release shall be governed by and construed in accordance with the internal laws of the State of North Carolina without giving effect to any choice or conflict of law provision or rule (whether of the State of North Carolina or any other jurisdiction). Any claim or cause of action arising under this Agreement may be brought only in the federal and state courts located in Lee County, North Carolina and I hereby consent to the exclusive jurisdiction of such courts.

Parent/Guardian Initial:

CCCC Camp Consent

Parental Consent Agreement
The policies and procedure can be found at www.cccc.edu/yes. By registering my child, I agree to adhere to the following policies: I will take responsibility for ensuring that he/she complies with appropriate student behavior guidelines, Students and their parents should understand that unruly behavior will be subject to student dismissal from the program with no refund. I also take responsibility for ensuring that my child arrives on campus no more than 30 minutes prior to the start of the program and is picked up promptly at the end of the program.

Film and Photography Release
Occasionally, Central Carolina Community College (CCCC) photographs and/or videotapes during the Youth Enrichment Programs (YES). Photos and videos are used for many different purposes, including social media, college website, publications, advertising, and promotional materials. We need your signature on file if you give your permission to use photos/videos of your child for promotional purposes. I consent to and authorize CCCC to take photographs, in film, digital, or print form of my child to be used for the purpose of promoting the CCCC Youth Programs without compensation to me. All film and images are the sole property of CCCC.

Permission to Use Testimonials
I give permission for my child's testimonial to be published in future publications. Testimonials may be taken from class projects or camp evaluations.

Permission to Travel by College Van
I give permission for my child to be transported to summer program activities by van. I acknowledge that my child must abide by the rules and regulations of the college. Parents(s)/Guardians(s) will be contacted by our staff following incidents which may result in dismissal from the program, with no refund.

Parent/Guardian Initial:

CCCC Camp Policies and Procedures

FEES AND CAMP DETAILS
Parent/guardian is response for all applicable camp fees.

REQUIRED FORMS
All participants in the CCCC Camps must have a Parental Waiver and Release, Consent Form, and Emergency Medical Form on file.

WAITLIST AND NO-SHOW POLICY
If your student will be unable to attend the CCCC Camp session for which they are registered, please contact CCCC staff as soon as possible so we may make the spot available to another participant. If the student fails to attend on the first day of their registered session and you do not notify CCCC staff, their registration will be cancelled and the spot will be offered to someone on the waitlist. Failure to notify CCCC if your student will be unable to attend will result in the student being prohibited in enrolling in future camps.

BEHAVIOR POLICY
All students are expected to maintain appropriate and respectful behavior while attending the CCCC Camps. If a student is disruptive, disrespectful or inappropriate, or jeopardizes the safety of others, parents will be asked to pick up their child. If the behavior continues, staff reserves the right to dismiss the student from the program.

DROP OFF AND PICK UP PROCEDURES
Parents and/or guardians are expected to sign in and out their camper upon arrival and pick up at designated campus locations during the times listed on your confirmation email. Repeated tardiness in drop-off or pick-up your student may result in the student being removed from the program.

LUNCH AND SNACKS
Students in the CCCC Camp will be provided with lunch and snacks. To avoid issues related to allergies or the dietary needs of other students, please do not send snacks or other food unless your student has specific dietary needs or restrictions. We encourage your student to bring a refillable water bottle for use during the program.

MEDICATION POLICY
If you indicated on your EMF that your student requires medication during camp, you will be asked to provide the medication to the camp director each morning. The camp director will store the medication and make it available to the student as requested. The student must administer the medication themselves; camp staff cannot administer any medications.

Parent/Guardian Initials:

Payment Information

Thank you for your interest in CCCC's Summer Camps. A staff member will review your request and send you a confirmation via email within 2 business days.

If you are registering for the waitlist, select "Waitlist registration only" as your payment method. Payment will be required if/when your camper is removed from the waitlist.

You are registering for the waitlist. Payment will be required if/when your camper is removed from the waitlist.

How would you like to pay?

WAITLIST REGISTRATION ONLY-No payment required at this time

Credit Card/ACH

Amount Due
Transaction Fee	Dependent on selected payment type
Total	Dependent on selected payment type
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Amount Due

Transaction Fee

Dependent on selected payment type

Total

Dependent on selected payment type

Your camper's spot will be reserved for 5 business days. If payment is not received, your space may be given to the next person on the waitlist.