Today's Date:

① Camper's Information

Full Name *

Preferred Name

Date of Birth *

Age *

Gender *

Male Female

Shirt Size *

YS
6–8 | 26–28" YM
10–12 | 28–30" YL
14–16 | 30–32" AS
34–36" AM
38–40" AL
42–44" AXL
46–48"

*** Campers will receive size ordered. If you request another size you will be responsible for purchasing it. Please wear knee-length shorts & closed-toe shoes.

② Primary Information

★ Mother / Guardian

Full Name *

Home Phone

Cell Phone *

Address

Work Phone

Email *

★ Father / Guardian

Full Name

Home Phone

Cell Phone

Address

Work Phone

Are there any court orders relating to the child's custody? *

Yes – I will provide a copy of the court order

Emergency Contact / Authorized Pick-up Information

In addition to names listed above. All authorized persons must be 18+ and present valid photo ID.

#	Name	Relationship	Phone

③ Health History

Current Medications (name, dose, times)

Known Allergies

Operations or Serious Injuries

Disability / Chronic / Recurring Illness

Activities Limited by Physician

Dietary Modifications / Considerations

Physician Name & Phone *

Hospital Preference & Phone

🏊 Swimming Consent

Ages 5–8 will enjoy the Splash Pad · Ages 9–12 (only) will swim at Zemurray Park public pool · A lifeguard will be on site.

My child IS allowed to swim / use splash pad

My child is NOT allowed to swim / use splash pad

④ Liability & Consents

Registration Policies: Deserving Minds Teaching & Learning, LLC does not discriminate based on race, creed, color, religion, or national origin. The organization reserves the right to refuse an applicant or dismiss a child from camp. No refund will be made if the child has attended any portion of camp. Full Summer Camp only — no partial sessions. No partial payments accepted. No application accepted without payment.

Parent / Guardian Signature *

Date

⑤ Enrollment Agreement

I will sign my child in and out daily and provide a valid photo ID.
Any authorized person picking up my child must be listed on this application, be at least 18 years of age, and present valid photo ID.
If my child remains past closing, I agree to pay $1.00 per minute per child (unless Before/After Care is arranged).
More than 4 late pick-ups may result in termination from the program without a refund.
The organization reserves the right to refuse/discontinue services for misconduct. No refund will be issued.

Before / After Care Interest

Before Care (7:30 am) – $5/day or $20/week cash

After Care (4–5 pm) – $5/day or $20/week cash

Payment Method *

Digital (Website)

Cash

Check

Money Order

Additional Notes / Information

Parent / Guardian Signature *

Date

💳 Step 2 — Complete Your Payment

Payment is required to secure your child's spot. Registration fee: $20 (one-time) + $120/week per camper. After submitting this form, please complete payment using one of the options below. Include your child's full name in the payment memo.

🅿️ Pay with PayPal paypal.me/YourLink 💸 Pay with Cash App $BLHammond 🟦 Pay with Square Pay Online via Square

Cash and money orders also accepted — contact us at 225-362-1860

Questions? Call 225-362-1860 or email learn@deservingminds.com
Mon–Fri 8am–4pm · deservingminds.org

Registration Submitted!