Summer Tutoring Program - Online Registration Mount Calvary Baptist Church Date: June 18 - July 11, 2019 Time: 12:00 pm - 3:00 pm PARTICIPANT INFORMATION Child #1 Last Name(*) Invalid Input First Name(*) Invalid Input Gender(*) FemaleMale Invalid Input Age(*) Invalid Input School(*) Invalid Input Last Grade Completed(*) Invalid Input Does your child have any learning disabilities? (*) Invalid Input Child #2 Last Name Invalid Input First Name Invalid Input Gender MaleFemale Invalid Input Age Invalid Input School Invalid Input Last Grade Completed Invalid Input Does your child have any learning disabilities? Invalid Input Child #3 Last Name Invalid Input First Name Invalid Input Gender Male Female Invalid Input Age Invalid Input School Invalid Input Last Grade Completed Invalid Input Does your child have any learning disabilities? Invalid Input Home Address(*) Invalid Input City(*) Invalid Input State/Province(*) Invalid Input Zip Code(*) Invalid Input Country(*) Invalid Input Telephone(*) Invalid Input Mother's Name(*) Invalid Input Mother's Day Phone(*) Invalid Input Mother's Cell Phone(*) Invalid Input Mother's Email Invalid Input Person Authorized to pick up child(*) Invalid Input Father's Name(*) Invalid Input Father's Day Phone(*) Invalid Input Father's Cell Phone(*) Invalid Input Father's Email Invalid Input Emergency Contact(*) Invalid Input Relationship(*) Invalid Input Emergency Contact Phone(*) Invalid Input You have my/our permission, in the event of an emergenceny and in case I am/ we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my child as they may deem advisable.(*) yesno Invalid Input Parent/Legal Guardian Name(*) Invalid Input Emergency Contact(*) Invalid Input Relationship(*) Invalid Input Phone(*) Invalid Input Specify any of your child's health problems(*) Invalid Input Is your child on any medication(*) yesno Invalid Input If so, please specify(*) Invalid Input If so please specify(*) Invalid Input Student Medical Problems(*) Invalid Input Doctor(*) Invalid Input Doctor's Phone(*) Invalid Input Insurance Carrier(*) Invalid Input Policy Number(*) Invalid Input Captcha(*) Invalid Input