Summer Camp Registration Form

MIDLAND CHRISTIAN ACADEMY

10456 Old Carolina Road, Midland VA 22728
Summer Camp Information

Let the fun begin! Our campers will enjoy Themed Camps Filled With Arts & Crafts, Indoor/Outdoor Activities, Water Fun, and more!

Age Requirements: Ages 3-10 years of age.

Camp Hours: Half Day 9:00am-Noon| Full Day 9:00am-4:00pm

Dress Code: Campers should be dressed in light, comfortable play clothes and sneakers. NO SANDALS, CROCS, FLIP FLOPS, OPEN-TOED SHOES!

Food: Please send lunch and snacks for your child daily.

Payment Policy: A Non-Refundable Deposit of $50 per child is due at time of registration using Square. All Deposits will be applied to tuition. Tuition Payments can be made by Check payable to MCA or by ACH/Credit Card using Square (3% Service Charge). Payments are due prior to start of your child's selected camp weeks, or at time of registration.

New Camper Fees: $50 Registration | $150 per week for 1/2 Day Camps | $250 per week for Full Day Camps

MCA Student Camper Fees: $50 Registration | $150 per week for 1/2 Day Camps | $200 per week for Full Day Camps

Sibling Discount: Sibling & Friend discount available.
Camp Options
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
9AM-NOON (HALF DAY)9AM-4PM (FULL DAY)
Camper's Information
Camper's Information*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information #1
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Parent/Guardian Information #2
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Authorized Person(s) to pick up Children (Other Than Parents)

(Must include atleast ONE local persons to call for illness, accident, late pick-up, or other emergency reasons.) Please list in order of preference for contact.
Name*

First NameLast Name
Phone Number*
undefinedFormat: (000) 000-0000.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Medical Information
Child's Physician/Clinic*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Medical Insurance*
Does the camper have any allergies, chronic illness, Special Physical Conditions or medical conditions? If yes, please describe.
Medications currently taking: (if not taking any please put none)*
Consent to medical care/treatment of minor child

I hereby give permission that my child may be given emergency treatment, to include first aid and CPR by qualified staff member of Midland Christian Academy.

I further authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by my child’s regular physician, or when that physician cannot be reached, by a licensed physician or hospital when deemed necessary or advisable by the physician to safeguard my child’s health if I cannot be contacted. In such case, I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance to an emergency care center/hospital for treatment. I agree to accept all responsibility for the cost of any medical services.
Initials*

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I hereby authorize the use of my child’s image for Midland Christian Academy’s promotional purposes. I understand that such images may include any film media of my child engaged in school related activities on or off the school property.I hereby DO NOT authorize the use of my child’s image/Video for Midland Christian Academy’s promotional purposes.
Initials*

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Student Handbook

I/we have read the 2025-26 Student Handbook found on the school’s website and agree to follow its policies.

Student Handbook
Initials*

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Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

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PAYMENT:

$50 per Child registration is required in advance to reserve your spot(s) and is non-refundable, regardless of attendance. Registration fee will apply to Camp Tuition. Tuition Invoicing will be emailed prior to start of Summer Camp.

REGISTRATION FEE (NON-REFUNDABLE) (REQUIRED TO HOLD CHILD'S SPOT)

Summer Camp Reg Fee

Registration fee will be applied to camp tuition.

$51.50 Number of Children
Item subtotal:$0.00

Total

$0.00

Credit Card

Check given to MCACASH given to MCAEmail Square Invoice (3% Service Charge)
Should be Empty:

MIDLAND CHRISTIAN ACADEMY

Camp Options

Camper's Information

PAYMENT:

Credit Card