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BH Summer Camp 2026 Registration
Camp Dates: June 9-July 24 , Mon. - Thr. 8AM - 3:00PM *No Camp June 30-July 4* Fill out this application and we will contact you if your student is accepted and give you further information.
There will be a mandatory parent meeting on Thursday, June 5 at 5:30 p.m. at Rescue Community Church (1924 Jonesboro Rd). Will you be able to attend?
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Yes
No
Completion of this form does NOT grant your student immediate acceptance into the BH Summer Camp. We accept BH After-School students first, then accept others as spots are available. We will contact you if your student has been accepted into the BH Summer Camp. If all spots are filled, your student will be placed on the waiting list. As spots open, we will call those on the waiting list. Please do not send your student to BH Summer Camp without having received a call.
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I understand and accept this information
Student Information
Student Name
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First Name
Last Name
Birthdate
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-
Month
-
Day
Year
Date
Age
Middle School attending
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Elementary School attended
Grade COMPLETED in 2024-2025 (No younger than 5th grade admitted)
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5th
6th
7th
8th
9th-12th (I am interested in applying to be a L.I.T.-Leader In Training)
Gender
Female
Male
Ethnicity
Caucasian
African American
American Indian
Hispanic/Latino
Asian
Other
T-Shirt Size (Please make sure this is the correct size for your student)
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Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Parent Information
Parent/Guardian Name
First Name
Last Name
Relationship to the Child
Parent
Aunt/Uncle
Step-Parent
Grandparent
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Total Number of persons living at address
Home Church, if any
Family Composition
Both Parents
Single Mother
Single Father
Grandparent
Other
Place of employment
Cell Phone
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-
Area Code
Phone Number
Home Phone
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Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Email
example@example.com
May we add your cell # to the BH “Remind” app so texts can be sent in case of emergency?
Yes
No
Does the child have a brother/sister in this program?
Yes
No
Emergency Contacts
Person to call in case of an emergency when you cannot be reached.
Emergency Contact 1
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First Name
Last Name
Relation to the Child
*
Emergency Contact 1 Phone Number
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-
Area Code
Phone Number
Emergency Contact 2
First Name
Last Name
Relation to the Child
Emergency Contact 2 Phone Number
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Area Code
Phone Number
Transportation
You will be responsible for providing transportation for your student. Drop off is 7:30-8:00 a.m. Pick up is at 3:00 p.m.
1. Person that is allowed to pick up my student (other than myself)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to the Child
2. Person that is allowed to pick up my student (other than myself)
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to the Child
Person that is NOT allowed to pick up my student
First Name
Last Name
Relation to the Child
Medical Information
Does your child have medical issues we should know about?
Does your student have an allergy or condition?
Yes
No
If yes, please list
Does this allergy or condition require medication to be kept and/or administered between the hours of 8:00 a.m. to 3:00 p.m.?
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Yes
No
Is your student currently taking medication for any mental or emotional condition?
Yes
No
List all prescription medications
Doctor Name
First Name
Last Name
Dentist Name
First Name
Last Name
Parental/Guardian Consent
Please read and click the buttons below to finalize your registration.
I give First West, Broaden Horizons and its representative’s permission to use photographs, video, digital and/or other images that includes my child in any and all media products for promotion, art, advertising, editorial, or other purpose. This may include, but is not limited, to newsletters, both print and email, posters, brochures, ads, post cards, social media, and web pages. I understand that the interviews that he/she grants and the filming, photographs, or digital images may be disclosed to First Baptist Church of West Monroe and/or Broaden Horizons for the sole purpose of advertising, marketing or generally promoting the social service programs, activities, and work First Baptist Church of West Monroe and/or Broaden Horizons offers to the general public. This authorization will continue as long as the child is involved in Broaden Horizons. I understand that I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. Theauthorization must be revoked in writing.
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Clicking here gives us your permission and is the equivalent of a signature.
I do NOT give my permission
I understand that my child’s participation in the Broaden Horizons Summer Camp depends upon his/her doing the following: Agree to have my child present 80% of the time or my child may be removed from the program. Completing all assignments and activities given to him /her by First West Broaden Horizons staff, teachers, and volunteers. Following the directions of the staff, teachers, and volunteers in the building, on the bus, and on field trips. Show the utmost respect to all staff, teachers, volunteers, guests, and other students. Agree to participate in all activities in the summer program (Field Trips, Educational Assignments, Bible Study, and etc.). I understand that my child’s participation in the program depends upon my making sure that my child follows the above instructions. I will inform First West Broaden Horizons when my child will be absent from the program for more than a week at a time. To serve your child and family, a home visit will be scheduled by a team member of the Broaden Horizons Summer Camp to help us better understand your goals and growth expectations for your child.
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Clicking here gives us your child permission to participate in the Broaden Horizon Summer Camp and is the equivalent of a signature.
Submit
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