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

Get Ready/Get Set Session 1, $720 (June 22 - July 2 8am-3pm)Get Ready/Get Set Session 2, $800 (July 6 - July 17 8am-3pm)Get Ready/Get Set Session 3, $800 (July 20 - July 31 8am-3pm)Get Ready/Get Set Session 4, $800 (August 3 - August 14 8am-3pm)Aim High, $1925 (June 22 - July 24, no camp 7/3 8am - 12pm)Aim High Afternoon (June 22 - July 24, no camp 7/3 12pm - 3pm) *I understand this will have an additional fee based on level of need

School Information*

School NameGrade in Fall 2026

YesNo

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):*

YesNo

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

Session 1Session 2Session 3Session 4

I Agree

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 AgreePlease contact me regarding upcoming field trips for individual permissionsI do not allow my child to attend any off campus field trips

I AgreeI do not allow my child to be photographed

I/We have read, understood and acknowledge the information on this form.

How did you hear about us?*

Please Specify*

Signature

Summer Camp Registration Form