Victorious Ministries

(Administration offices) East location – 4617 York Rd., Baltimore, MD 21212

West location – 3300 Glen Avenue, Baltimore, MD 21215

410-433-8066 / 410-433-8182

Pastor Tony Smith

Enrollment Application

Enclosed you will find our application. Please complete all forms. A separate Vital Information form must be filled out for each child you are enrolling. Copies of the following forms must accompany your application.

1. Birth certificate

2. Social security card

3. Immunization records

· As of June 1, 2012, a $35.00 per child, non-refundable REGISTRATION FEE must be paid when children are registered for (Camp Judah. Camp fees are $560.00 per child, total = $595.00)

Please make all checks and/or money orders payable to Victory Ministries.

List the name of child enrolling. (separate sheet for siblings)

Name Age

______________________

PARENTS INFORMATION

Parent(s)/Guardian Name: (mother & father can go on same line if applicable/same household)

_________________________________________________________

Home Address: _________________________________________________________

_________________________________________________________

Place of Employment: _________________________________________________________

Home Phone: Work Phone:

(please update all information, do not put “see last year’s application” Thank you ☺)

Enrollment Application

Page 2

Non custodial parent info ( if applicable) or mark N/A

Parent name: _________________________________________________________

Home Address: ____________________________________________________________________

(if both parents same, write “same”)

_________________________________________________________

Place of Employment: _________________________________________________________

Home Phone: Work Phone:

EMERGENCY CONTACT PERSONS (PLEASE LIST THREE)

NAME PHONE NUMBER RELATIONSHIP

1. _______________________________ _____________________ __________________

2. _______________________________ _____________________ __________________

3. _______________________________ _____________________ __________________

**Please list a valid email address (preferably frequently used) for information on updates, changes and/or emergencies.

Camp Judah 2012

Vital Information Form

(one for each child)

Child's Full Name: ____________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

Age: Date of Birth: Sex:

Social Security Number: ______________________________________

Please list any allergies, illnesses or physical limitations:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the child under a doctor’s care? _________

Please Explain:

Is the child on any prescription medication? _________

(Any medications to be taken on camp premises, MUST be accompanied by a doctors referral along with dosage instructions)

A Subsidiary of Victorious Ministries, Pastor Tony Smith – Founder & CEO

Vital Information Form

Page 2

Please check the specific area(s) of interest for your child

o Vocals/Choir

o Drama/Theater (Acting)

o Creative Writing/Poetry

o Dance

This does not mean they will not participate in any other area, it just allows us to know which one they are most comfortable in.

Please CIRCLE your child’s shirt size so that they may receive a camp T-shirt.

Small Medium Large XLarge

Victorious Ministries