2018 Front Porch Mentee Application

Child's Name

First Name Last Name

Gender: *

Day you would like student to attend Front Porch *

Grade in School

Birth Date *

Month Day Year

Age

Parent/Guardian Full Name: *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Number *

- Area Code Phone Number

Cell Number

- Area Code Phone Number

Do you work?

E-mail

We ask for emergency contacts so that if your child is not at school for pick-up or if there is another problem, we can still get in touch with you through a close friend/relative.

Emergency Contact *

First Name Last Name

Phone Number *

- Area Code Phone Number

Emergency Contact *

First Name Last Name

Phone Number *

- Area Code Phone Number

Why do you think the child would benefit from being a part of this program? *

What are the child’s personal interests, skills or hobbies, sports played? *

Describe any particular problems he/she might have. (i.e. emotional, behavioral, mental, social, academic, etc) *

Is the child having any problems in school?

If yes, please explain:

Does he/she have any kind of health problem or physical disability? *

If yes, please explain:

Does the child have a parent or other relative currently in prison? *

If yes, please explain:

If yes, is the child aware of the situation? *

Church Name (If you attend)

Does the camper have any allergic reactions to food, or insect stings? If so, please describe.

Special Considerations (check all that apply):

Faint Epilepsy Diabetes Hay Fever Asthma ADD ODD

I give permission for my child to receive (check all that apply):

Tylenol Ibuprofen Allergy Medication Anti-itch cream

My child will need transportation to Camp David of the Ozarks Front Porch Program.

Yes No

School's Name

Pick-up Time:

Phone Number

- Area Code Phone Number

Parental Permission & Release
(This must be signed to include your child in the program.)

"I understand that while attending Camp David of the Ozarks Front Porch Program my child may be involved in various activities including, and not limited to, horse rides, obstacle courses, and field games. I understand the mission of Camp David of the Ozarks is to provide a Chrisitan Camp where one can experience love, find hope, and grow in a relationship with Jesus Christ. I do hereby grant permission for my child to attend Front Porch and participate fully in all activities. I have instructed my son/daughter to obey the rules of Camp David of the Ozarks Front Porch Program. I understand that should my child become very disruptive I may need to make arrangements to pick them up. I also give permission to Camp David of the Ozarks Front Porch Program to use camp pictures of my child in promotional and sponsorship material. I also give permission to Camp David of the Ozarks Front Porch Program to pick up my child from the aforementioned school and drop them off at a specified location so they can attend Front Porch."

By typing my name below I agree to the above statement.

First Name Last Name

Relationship to child:

Date Signed:

- Month - Day Year

2018 Front Porch After-school Program

Information about your child

Health Record & Release Form

Transportation