New Orleans Cultural Immersion

New Orleans and the American South Cultural Immersion

Please remember deposit is due by Decmeber 10th
Student Info
Last Name
First Name
Middle Name
Gender
Address
City
State
Zip
Home Phone

Area CodePhone Number
Emergency Contact Name(if parent or guardian is not avaliable)
Emergency Number

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date

MonthDayYear
Current Grade
Parent or Legal Guardian Information
Parent/Legal Guardian
Relation
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2
Relation 2
Work Phone 2

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Email Confirmation
Parents Email (Will be used for all communication)
Students's Email
Other Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. We will get updated information the closer we get to depature date.
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the student should be restricted from?
Any physical, mental or other condition that would require special attention or medication while at camp?
List any past medical treatment that would be helpful for us to know.
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.
Payment Information

$200 Deposit Due 12/10
Method of Payment
prevnext( X )
(Paypal or Credit Card)+Processing Fee$201.50

Zelle 720-355-4151 Free
If paying with PayPal you will be redirected to PayPal once you hit submit. You can either pay with credit card, or PayPal. There is a $1.50 processing fee for using this option. The remaining balance on invoice will remain open until paid off. If you have any questions feel free to contact Kisha at 72-355-4151.
Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named student, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named student by authorized personnel. I certify that my child has my permission to attend and participate in all activites. I authorize Kids Life Inc to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the Kids Life Inc.
Signature
Electronic signature, please initial
Should be Empty:

New Orleans and the American South Cultural Immersion

Student Info

Parent or Legal Guardian Information

Email Confirmation

Other Information

Payment Information

Method of Payment