Mount Calvary Baptist Church - Mount Calvary Baptist Church
One Church two locations, A Multi-Ethnic Ministry

Summer Tutoring Program - Online Registration

Mount Calvary Baptist Church Summer Tutoring Program June 28 - July 19, 2018
PARTICIPANT INFORMATION
Child #1
Last Name(*)
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First Name(*)
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Gender(*)
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Age(*)
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School(*)
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Last Grade Completed(*)
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Does your child have any learning disabilities? (*)
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Child #2
Last Name
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First Name
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Gender
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Age
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School
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Last Grade Completed
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Does your child have any learning disabilities?
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Child #3
Last Name
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First Name
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Gender
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Age
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School
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Last Grade Completed
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Does your child have any learning disabilities?
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Home Address(*)
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City(*)
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State/Province(*)
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Zip Code(*)
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Country(*)
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Telephone(*)
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Mother's Name(*)
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Mother's Day Phone(*)
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Mother's Cell Phone(*)
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Mother's Email
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Person Authorized to pick up child(*)
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Father's Name(*)
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Father's Day Phone(*)
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Father's Cell Phone(*)
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Father's Email
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Emergency Contact(*)
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Relationship(*)
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Emergency Contact Phone(*)
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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.(*)
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(*)

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Emergency Contact(*)
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Relationship(*)
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Phone(*)
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Specify any of your child's health problems(*)
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Is your child on any medication(*)
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If so, please specify(*)
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If so please specify(*)
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Student Medical Problems(*)
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Doctor(*)
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Doctor's Phone(*)
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Insurance Carrier(*)
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Policy Number(*)
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Captcha(*)
Captcha
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