2016 Summer Camp

Father's Work Number *

Mother's Work Number *

Other Relation to Child *

First

Last

Relation to Child *

Cell Number *

Work Number *

NUMBERS TO BE USED FOR "ONE CALL SYSTEM" WHICH WOULD RECEIVE VOICE, TEXT, EMAIL AND MESSAGING

EMERGENCY INFORMATION AND AUTHORIZED PICK UP PERSONS OTHER THAN YOURSELF

PERSON WHO HAS FINANCIAL RESPONSIBILITY FOR TUITION AND OTHER SCHOOL RELATED FEES

UNAUTHORIZED PICK UP

HEALTH INFORMATION

School must have copy of insurance card

I understand that it is my responsibility to keep 29:11 Mentorship program aware if there are any changes to the above information. I understand that if my child is to be given prescription medication during program hours, it is my responsibility to fill out a “Parental Consent For Medication” form.

In the event of illness, I give permission for my child to take the following during the time my child is with the 29:11 Mentorship program: (please check) *

Tylenol Advil Antacid Nothing

By completing this registration form, I understand and agree that, if need be, I give the 29:11 Staff approval to discipline my child through verbal correction, time-out sessions, suspension, paddle, or ultimately expulsion. *

I agree

By submitting below, I am stating that all above information is accurate and true and I agree to the electronic communication terms within this form.

Only paid applications will be granted the opportunity for enrollment in the 29:11 Mentorship Program.
Any questions please contact Tremaine Sterling at 225-287-1344.

You will be redirected to PayPal to pay the Registration Fee ($50.00), Week 1 Payment ($80) and Week 2 Payment ($80) all due at time of registration (Total $210).

Please click ADD by "Add Student's Name HERE" or "other info" (under the shipping address verification section) and type student's name in the box.