2023 SUMMER CAMP AT THE MOUNT

Mount Pleasant Baptist Church 215 Rhode Island Avenue, NW • Washington, DC 20001 Tel: 202.332.5748 • Fax: 202.986.0531 • Web: www.mpbcdc.org

$150.00 per week per child (2^nd child in the same family is $125.00 and 3^rd child in the same family is $100.00)) includes meals and field trips. Children will enjoy academic enrichment, swimming, and outings to museums, parks, and more. 7:00am to 6:00pm

NOTE: IF NOT PAYING UPON REGISTRATION, WHEN COMPLETE HIT SUBMIT AND BACK OUT.

APPLICATION

CAMPER INFORMATION

Camper 's Name: *

Select One:

1st Child $150.00

2nd Child $125.00

3rd Child $100.00

Age at camp this summer:

Date of Birth: *

Grade Entering Fall 2023:

Gender: *

Male

Female

PARENT/GUARDIAN ADDRESS WHERE CAMPER RESIDES

Mother's Name: *

Father's Name: *

Home Address

Country

City

State

Zip code

Home Phone

Work Phone

Cell/Alternate Phone *

EMERGENCY CONTACT INFORMATION (when parent/guardian cannot be reached)

Emergency Contact Name: *

Address

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Work Phone

Phone Cell/Alternate

HEALTH INFORMATION (Please write none or N/A for a negative response, no blanks.)

KNOWN ALLERGIES

LIST ALLERGIES ABOVE (Include food, drugs or other)

Known Medical Condition

Medication To Be Administered During Camp?

Last Physical Date

Instructions

MEDICAL RELEASE: (Please sign below) To my knowledge, my child is in good health and is capable of participating in a full sports program. In case of an emergency and when neither parent can be contacted by phone, I authorize the camp to take my child to any hospital emergency room, at my expense, and for the hospital to provide treatment that a physician deems necessary for the well-being of my child.

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