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About
EVENTS
Night of Hope 2018 Replay
Parenting On Purpose
Spring 2019
Schedule
Contact
Staff
Meet The Mentors
Request For Ministry
Gallery
Meet the Mentees
>
Meet our Leadership Team
Sponsors
29:11 Freeze
Feet2Faith
30 for 30
Leadership Trip
Day of Hope 2019
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
Schedule
Contact
Staff
Meet The Mentors
Request For Ministry
Gallery
Meet the Mentees
>
Meet our Leadership Team
Sponsors
29:11 Freeze
Feet2Faith
30 for 30
Leadership Trip
Day of Hope 2019