MHA Summer Camp 2026 Registration Form

Student Details:

Full Name

First NameLast Name

Date of Birth

Date

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Registration Information

I would like to enroll my child in the following programs:

School Information

School NameGrade in Fall 2026

My child has an Individualized Education Plan (IEP).

Please attach IEP

Medical Information:

Any prescription(s) medication taken regularly?

Allergies or medical conditions school personnel should be aware of (e.g., asthma, bee sting allergy, seizures):

I allow the staff to administer acetaminophen (e.g. Tylenol) to my child

My child has received all the immunizations and boosters necessary to attend school in California.

Parent/Guardian Information:

Parent/Guardian #1

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address (if different from student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian #2

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address (if different from student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child resides with:

If parents are divorced or leagally seperated and there is a custody agreement, please describe the arrangement

Attach Court Document (if applicable)

Emergency Contact Information:

Emergency Contact Person 1

Full NamePhone Number

Emergency Contact Person 2

Full NamePhone Number

Alternate Driver 1

First NameLast Name

Alternate Driver 2

First NameLast Name

Alternate Driver 3

First NameLast Name

Payment Consent:

Total Cost:

Session 1: $720 Sessions 2-4: $800 Aim High: $1925

Please check below if you are in need of Before Camp care from 7:00am-8:00am at a rate of $8.50 per hour or After-camp care from 3:00pm-5:00pm at a rate of $8.50 per hour. Before and after-care charges are billed in 30 minute increments. Any student picked up after 5:00pm will be billed at a rate of $2.00 per minute. Please check all that apply

Before Care

After Care

A $350.00 deposit per session is due upon registration for Get Ready and Get Set Programs. An $800.00 deposit for Aim High is due upon registration. Please note, deposits are non-refundable. Cancellations on or after the first day of camp will not be refunded.

There are no refunds for days missed due to absence or illness.

I agree to pay when billed all other fees and charges incurred in association with student's enrollment in camp, including charges for before and after care.

Credit Card and Debit Card payments will be charged an additional three percent (3.0%) of the payment amount. By checking this Box you are agreeing to these terms.

Additional Permissions and Information:

I/we understand and agree that my student may be taken on certain field trips during the school day and that, if transportation is required, it will be provided by the school's vehicles driven by staff members who are approved drivers, or it will be provided by public transportation, and/or the school will contract for transportation with a common carrier who is properly licensed and is insured for liability at appropriate levels. In the event of accident, illness, injury, and/or death to the student when being transported by public transportation or contracted common carrier, we agree to save and hold harmless and waive all claims against Mt. Helix Academy, TIEE, its Officers and Board of Directors, and its employees. By checking this box you are agreeing to these terms.

I/We understand and agree that the student can be photographed and/or videotaped by the school for archival purposes, for professional training purposes, and/or promotional purposes and, further that there will be no compensation paid by the school. By checking this box you are agreeing to these terms.

By checking the box below you are agreeing that you have answered all of the items on this form accurately and we provide all the permissions requested on the form. We accept responsibility for informing the school of any changes in the information we have provided and acknowledge that the school's ability to provide for our child's health and safety may depend on the information provided.

How did you hear about us?

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Summer Camp Registration Form