Mentors In Motion: Music, Merch and More Summer Camp Registration Form
Mentors In Motion is providing a Music, Merch and More Summer Program for youth ages 09 -17 at Mission: Saint Louis. This summer camp is designed to engage youth with activities from our Workforce Development Platform and engage students into financial literacy, business structure and more. Summer Dates:June 3rd-July 25th Location: 3108 N Grand Blvd, St. Louis, MO 63107 Summer Camp Hours: 9:00 a.m. - 4:00 p.m. Disclaimer: Mentors In Motion Saturday camps are exempt from State of Missouri childcare licensure and are not regulated by the Office of Childhood.
Student Name
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First Name
Last Name
Student Grade
*
Student Date of Birth
*
Student Age
*
Student Current School
*
Student Race/Ethnicity
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Black/ African American
White/ Caucasian
American Indian or Alaska Native
Asian
Hispanic
Native Hawaiian or Other Pacific Islander
Other
Rate the following based on your students interest: Music Production
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Least Interested
1
2
3
Most interested
4
1 is Least Interested, 4 is Most interested
Rate the following based on your students interest: Song Creation
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Least Interested
1
2
3
Most interested
4
1 is Least Interested, 4 is Most interested
Rate the following based on your students interest: Video Production
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Least Interested
1
2
3
Most interested
4
1 is Least Interested, 4 is Most interested
Rate the following based on your students interest: Merch Creation (i.e T shirts hoodies etc.)
*
Least Interested
1
2
3
Most interested
4
1 is Least Interested, 4 is Most interested
Parent/ Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
*
First & Last Name
Relation to Student
Student's Authorized Pick Up
*
Name
Relation
Authorized Pick up Contact
*
Please enter a valid phone number.
Mentors In Motion has my permission to transport my child to and from weekly fieldtrips offsite
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Yes
No
Please specify your household income below (we need this information for grant reporting purposes only)
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Under $20,000
$20,000- $34,999
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
Other
If your family needs any additional resources/ Support please describe in the comment box.
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