PSALMIST RAINE MINISTRIES
Home
About Psalmist Raine®
Press Releases
The ReFresh Institute/ReFresh Global
Cultivate Inc.
Contact Us
Forever Evolving Youth Summer Empowerment Dance Camp
Please complete the registration form for participation in this summer camp program.
*
Indicates required field
Participating Youth Name
*
First
Last
Age
*
Parent/Guardian Contact Information
Parent/Guardian Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Please complete with valid email address. All information regarding this program will be sent to this email address
Emergency Contact
In case of emergency, please provide emergency contact information for the participating child.
Emergency Contact 1 Name
*
First
Last
Emergency Contact 2 Name
*
First
Last
Phone Number
*
Phone Number
*
Medical Information
Medical Information
*
Please provide any vital medical information that we may need to be aware of for your child during this time.
Approved Pick Ups
Approved Pick Up Name
*
Please provide first and last name for approved pick up.
Approved Pick Up Name
*
Please provide first and last name for approved pick up.
Approved Pick Up Name
*
Please provide first and last name for approved pick up.
Allergies
*
Please provide any allergic information necessary; as we will provide breakfast & lunch snacks.
Relationship to Participating Youth
*
Mother
Father
Sister
Brother
Cousin
Grandparent
Aunt
Uncle
Friend
Please click on dropdown box to put the appropriate relationship to the participating youth.
Relationship to Participating Youth
*
Mother
Father
Sister
Brother
Grandparent
Cousin
Aunt
Uncle
Friend
Please click on dropdown box to put the appropriate relationship to the participating youth.
Relationship to Participating Youth
*
Mother
Father
Sister
Brother
Grandparent
Cousin
Aunt
Uncle
Friend
Please click on dropdown box to put the appropriate relationship to the participating youth.
Submit
Home
About Psalmist Raine®
Press Releases
The ReFresh Institute/ReFresh Global
Cultivate Inc.
Contact Us
©2016 Copyrights & Rights Reserved by Psalmist Raine Ministries, LLC.