MJ Rodges Summer Bible School Application
Please complete this application in its entirety. Upon completion, you will be directed to remit your $50 application fee and first week's fee. You child's spot will only be secured once both of these payments have been submitted.
Child's Full Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Current Age
*
Gender
*
Please Select
Male
Female
T-shirt size
*
(Youth sizes)
Do you require extended care hours?
Yes
No
Grade Completed
*
School Attended
Are you registering more than one child?
Yes
No
Child's Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Current Age
Gender
Please Select
Male
Female
T-shirt size
(Youth sizes)
Grade Completed
School Attended
Mother's/Guardian's Name
*
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Father's/Guardian's Name
*
First Name
Last Name
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Emergency Contact Person (not listed above)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Health Comments (allergies, health problems, medications, etc.)
Health Provider
Health Insurance Company
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
The following adults are authorized to pick up my child
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
By signing below, I am acknowledging that all information completed is accurate and will inform the camp if any changes occur.
*
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Use of Photograph Release
I hereby give MJ Rodges Summer Bible School the absolute and irrevocable right and permission, with respect to the photographs that have been taken of my child or in which my child may be included with others, to use, re-use, publish, and re-publish the same, in whole or part, individually, or in conjunction with other photographs, in any medium and for any purpose whatsoever, including (but not by way of limitation) illustration, promotion, and advertising and trade, television and multimedia, and to use my child’s name in conjunction therewith if MJ Rodges Summer Bible School chooses. I hereby release and discharge MJ Rodges Summer Bible School from any and all claims and demands arising out of or connection with the use of photographs.
*
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Additional Waivers and Acknowledgements
*
I/We understand this Behavior Contract and will abide by its rules and policies, which have been established for the safety and enjoyment of all participants. I also understand that MJ Rodges Bible School will make every effort to work with each child. However, if the child does not want to behave and be part of his/her group, steps will be taken to insure that the total is not affected by the few.
*
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Payments and Fees
*
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( X )
Camper Registration Fee
$
50.00
Quantity
1
2
3
4
Camper Weekly Fee (JBC Member)
This fee covers the first week of camp for 1 child
$
85.00
Quantity
0
1
2
3
4
Camper Weekly Fee (JBC Non-Member)
This fee covers the first week of camp.
$
95.00
Quantity
0
1
2
3
4
Credit Card
Submit
Should be Empty: