2023 Student Life Camp Registration 2023 Student Life Camp Date * Family Information Student's Name (First + Last) * Grade * 6 (MS) 7 (MS) 8 (MS) 9 (HS) 10 (HS) 11 (HS) 12 (HS) Student Email Address (Optional) This will be used to send a copy of this registration form, and other important trip updates Student Phone (Optional) Parent Email Address * This will be used to send a copy of this registration form, and other important trip updates Mother's Name (First + Last) or Legal Guardian * Mother's/Legal Guardian's Phone * Father's Name (First + Last) * Fathers's Phone * Church You Most Often Attend * MPBC OtherOther Trip Information Payment Cash/Check App/Kiosk/Web A $50 deposit will save your spot for the trip. Remainder of cost due before retreat. If paying by credit card, use your MPBC App or pay on our website (this link will be in your confirmation email). Please forward the payment receipt to lyana.smith@mpbclife.com - this will help us greatly! If paying by cash/check, put in envelope in Black Box by church office door. T-Shirt Size * X-Small Small Medium Large X-Large XX-Large Anything we should know about your child? Emergency Contact * Emergency Phone * Is your child bringing a friend * No YesYes Roommate Request(s) More than one request can be added, but only the first one will be guaranteed Has your child attended an overnight event in 2023 yet? * Yes, so I filled out a Medical Release for 2023 No, I need to fill it out Medical Release Information Family Physician * Physician Phone * Family Insurance Co. * Insurance ID Number * Insurance Phone * Does your child have any of the following? * Asthma Sinusitis Bronchitis Kidney Trouble Heart Trouble Diabetes Seizures Stomach Upset Hay Fever OtherOther Explain/Additional InfoExplain/Additional Info **None of the above** Allergies * FoodFood Penicillin or other drug (name)Penicillin or other drug (name) Insect stings/bitesInsect stings/bites Poison Sumac, Oak or IvyPoison Sumac, Oak or Ivy OtherOther **None** If you choose one, a text box for more information will appear. Childhood Diseases * Chickenpox Measles Mumps Whooping Cough **None of the Above** Is your child up to date on immunizations for Tetanus, Polio Booster, Measles, Mumps, and others? * Yes No (please note)No (please note) Special Diet (name) Please list all medications your child is taking: Can we give your child any of these medications if the situation arises where they need it? * Tylenol (Acetaminophen) Motrin (Ibuprofen) No Medical & Travel Release The paper Registration and Medical Release form will be created with the information on this digital form. The following release will be included: "My permission is granted for any Mount Pleasant Baptist Church staff member to obtain medical attention in case of sickness or injury for (student's name). "I/We, the undersigned, do hereby release, remise and forever discharge all sponsors and Mount Pleasant Baptist Church, Colonial Heights, Virginia, from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in this event. I also agree to pick up my student or reimburse MPBC for the cost of sending my student home in the event that he/she commits any infraction of the rules, puts their fellow participants in danger, or exhibits a disruptive attitude." I understand that I will have to check my child in and make sure that all of my child's forms and payments are turned in. I understand my child may not be dropped off without checking in. * Yes, I understand and agree No, I need to talk to Lyana or Luke to resolve something If you are human, leave this field blank. Submit Δ