MIB&G REGISTRATION FORM Please enable JavaScript in your browser to complete this form.What program are you registering your child for?Summer Camp ProgramSchool Year ProgramChild's name *Child Date of BirthMother's NameFirstLastMother's EmailMother's PhoneFather's Name FirstLastFather's EmailFather's PhoneEmergency Contact Nameif parent or guardian cannot be reachedEmergency Contact RelationshipEmergency Contact PhoneDoes child have any food allergies/medical conditions? *YesNo(if yes, please provide details below)Details of food allergies, medical conditions: Parental PermissionsI give permission for my child to be photographed &/or videotaped for promotional useI do NOT wish for my child to be photographed &/or videotapedI give permission for my child’s writing to be publishedI do NOT wish for my child’s writing to be publishedIs your child/student an introvert or extrovert or somewhere in between?Does your child/student work well in groups or is he/she more productive working alone?Does your child/student learn better with verbal directions, written instructions, or hands on?What art form would your child/student benefit the most from?DanceSingingTheaterCreative WritingStep DanceWhen your child/student is offended, threatened, or disrespected , what are they more likely to do? Bring the matter to an authority figureLash out at othersOn a scale of 1-10, where do you feel like your child/student ranks when it comes to listening and following directions? Selected Value: 0 On a scale of 1-10, where would you rank your child/student when it comes to being empathetic towards other children? Selected Value: 0 On a scale of 1-10, where would you rate your child/student artistically? Selected Value: 0 Is there anything else you would like to share about your child/student?I will make sure my child arrives at the MIB&G Program on time and ready to learn. I will also pick my child up on time. I understand that I will incur a late fee of $1/minute after 5 minutes I am late picking up my child and every day after the 5th of the month that my child’s tuition is not paid.I agreeI promise to support my child’s participation by helping him/her learn lines, ensuring that they receive adequate rest and encouraging family, friends, coworkers and church members to support the final performance and MIB&G community activities. I agreeWe have a 4-strike expulsion policy regarding behavior. The first strike is verbal, the second strike will be written, the third strike will result in a one-week suspension, and the final strike will result in expulsion from the Program indefinitely. I agreeBecause of our many years of working with youth, we know that two or three kids can disrupt the learning process. Every parent has paid money for their child(ren) to have a good time, learn and to feel safe. If in any way your child prevents others from experiencing these things, they will be expelled from the Program and there will not be any reimbursement. We feel that 3 opportunities for them to get it right is more than enough. Our hope is for every child to make it through the School Year Program and experience nothing but good feelings as a result of this amazing program. I understand that if there is no negligence or inappropriate behavior by the staff regarding your children, there will be no refund issued.I agreeSignatureDateSubmit
