Summer Camp Registration – Mt. Sinai Missionary Baptist Church

MSMBC Summer Camp Registration

Full Name

Date of Birth

Age

Gender

Grade Applying for

Current/Previous School

Home Address

City

State

Zip code

Church Affiliation

Has the student made a personal commitment to Christ?

Brief Testimony

Parent /Guardian (1) Name

Relationship to Student

Phone Number

Parent /Guardian (2) Name

Relationship to Student

Phone Number

Church Home

Are you members?

Does Your Family Attend Regularly?

Has Your Child ever been suspended?

Has Your Child ever been expelled?

Has an IEP or a 504 Plan

If yes please explain

Any Know Allergies or Medical Conditions

Medications currently taking

Emergency Contact Name (other than parent)

Emergency Contact Phone Number (other than parent)

Consent/Signature

I/we affirm that the information provided is true and complete. We understand that the Christian Academy integrates biblical principles into its academic program and agree to support the school's mission, values and policies.

Parent/Gardian Signature

Date

Parent/Gardian Signature

Date

Deposit

I understand that there is an $80.00 non-refundable deposit and the first week of summer camp. Payments are due weekly, and no student will be allowed to attend class unless payments are made.