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About
EVENTS
Night of Hope 2018 Replay
Parenting On Purpose
Spring 2019
Calendars
Schedule
Contact
Staff
Meet The Mentors
Request For Ministry
Gallery
Meet the Mentees
>
Meet our Leadership Team
Sponsors
29:11 Freeze
Feet2Faith
Fill out the registration form online below
Then pay the Registration Fee via PayPal (All major cards accepted)
Orientation Presentation Here
2016 Summer Camp Registration
June 6 - July 22
Park Forest Middle School
3760 Aletha Dr., Baton Rouge, LA 70814
*
Indicates required field
Student's Name
*
First
Last
Phone Number
*
School Attending
*
Grade
*
Date of Birth (MM/DD/YYYY)
*
Gender
*
Male
Female
Student's Social Security Number
*
Student's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Race
*
Shirt Size
*
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
X-Large
XX-Large
With Whom Does Student Reside?
*
Father and Mother
Mother Only
Mother and Stepdad
Father Only
Father and Stepmom
Other Relation to Child
Please give Guardian's Contact Information According to the Previous Question's Response
Father's Name
*
First
Last
Father's Cell Number
*
Mother Name
*
First
Last
Mother's Cell Number
*
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
Father's Number
*
You can choose for one or both parents to receive the "One Call" messages
Father's Email
*
Mother's Number
*
You can choose for one or both parents to receive the "One Call" messages
Mother's Email
*
EMERGENCY INFORMATION AND AUTHORIZED PICK UP PERSONS OTHER THAN YOURSELF
Name #1
*
First
Last
Name #2
*
First
Last
Relationship
*
Relation to child of 1st emergency contact
Relationship
*
Relation to child of 2nd emergency contact
Home/Cell Number
*
Primary Number of 1st emergency contact
Home/Cell Number
*
Primary Number of 2nd emergency contact
Work Number
*
Work Number of 1st emergency contact
Work Number
*
Work Number of 2nd emergency contact
PERSON WHO HAS FINANCIAL RESPONSIBILITY FOR TUITION AND OTHER SCHOOL RELATED FEES
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Place of Employment
*
Position/Title
*
Years Employed at Current Job
*
Work Number
*
Cell Number
*
UNAUTHORIZED PICK UP
Person(s) not allowed to pick up my child
*
HEALTH INFORMATION
Medical Doctor
*
Phone Number
*
Has your child ever been diagnosed with the following illnesses?
*
Asthma
Heart Disease
Seizures
Diabetes
ADD/ADHD
Frequent Ear Infections
Glasses or Contact Lenses
Severe Allergies
Physical Defects
Other
Name of Medication, List of All Allergies
*
Explain other, name all medications, and also list all allergies in this box
Student's Driver's License Number
*
Student's Car Color, Make, and Model
*
School must have copy of insurance card
Church Currently Attending
*
Pastor's Name
*
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
.
Submit
Home
About
EVENTS
Night of Hope 2018 Replay
Parenting On Purpose
Spring 2019
Calendars
Schedule
Contact
Staff
Meet The Mentors
Request For Ministry
Gallery
Meet the Mentees
>
Meet our Leadership Team
Sponsors
29:11 Freeze
Feet2Faith
