In order for the admissions committee to consider your application, we must have all of the elements that are listed below completed and on file by May 30, 2005. Note: This is offered at a first come, first served basis.

1. Application, fee and photo

Please complete the Registration for Admission attach a recent photo and return it to the Perkins Center office with a $25 non-refundable registration fee and the first months tuition.

Office: 601-354-1563 · Fax: 601-362-6882

Date of Application: _______ Application Fee per child: ______ ($25 Non-refundable)

Child’s Shirt Size (Note: These are adult sizes) Circle One: S M L XL T-shirt fee $10_____

Name of Child ____________________________________ SS#_____-____-______ Age_____ Sex ______

(Please choose top three preferences by marking 1 for 1st choice, 2 for 2nd choice and 3 for 3rd choice.)

___Vocal Arts (choir/voice) ___Visual arts (drawing/murals) ___Video Production (making videos)

___Drama (acting) ___Dance (creative dance) ___Learn to play an instrument

Father/Legal Guardian___________________________ SS#____-___-_____ Phone # (     ) _____________

Mother/Legal Guardian__________________________ SS#____-___-_____ Phone # (      ) _____________

Who will be responsible for payment? _____________________

each child(ren) on the spot, when I do not arrive on time. Note: Late fees start at 6:01 p.m. Late fees are as

Your child(ren) will be released to only those persons listed below:

Required Income Information:

Medical Release and Authorization

If parent of legal guardian cannot be contacted during the time of emergency, the undersigned parent/legal guardian authorizes a representative of JMPF, SPC, and UYL to give consent to X-ray, anesthetic, or surgery if the need arises. I certify by my signature below that I have read, understand, and give consent to all the statements contained in this authorization.

Print – Name of Parent/Legal Guardian _________________________________________________________

Signature of Parent/Legal Guardian ______________________________________ Date _________________

Important: Each participant must have a signed “Release and Waiver of Liability” on file. Please complete this

form now in order to be considered. Please print information in blanks provided.

This Release and Waiver of Liability (the “Release”) executed on this _______day  of ___________, 2005 by_______________________________ (the parent/guardian) in favor of JOHN M. PERKINS

FOUNDATION, INC. (JMPF) AND THE SPENCER PERKINS CENTER (SPC), and BOWMAR BAPTIST

CHURCH (BBC), a nonprofit corporation organized and existing under the laws of the State of Mississippi,

USA, its affiliated organizations in other names, its, directors, officers, employees, and agents (collectively, the

“Foundation”).

I, ___________________(parent/guardian), give my permission to the John M. Perkins Foundation, Inc./

Spencer Perkins Center (JMPF/SPC/BBC), for my child, __________________, to engage in the

activities related to being a day camper. I understand that the activities may include but are not limited to,

traveling to and from other cities and towns, consuming food and participating in light work projects on the

grounds of the JMPF/SPC/BBC.

I, _______________hereby freely and voluntarily, without duress, execute this Release under the following

terms:

1. Waiver and Release. I, __________________, release and forever discharge and hold harmless the

JMPF/SPC/BBC and its successors and assigns from any and all liability, claims, and demands of

whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my child’s

participation at the JMPF/SPC/BBC.

2. Insurance. I, _____________________, understand that, except as otherwise agreed to by the

JMPF/SPC in writing; JMPF/SPC/BBC does not carry or maintain health, medical, or disability insurance

coverage for any student, volunteer or day camper.

3. Medical Treatment. Except as otherwise agreed to JMPF/SPC/BBC in writing, I hereby release and

forever discharge JMPF/SPC/BBC from any claim whatsoever which arises or may hereafter arise on

account of any first-aid treatment or other medical services rendered in connection with an emergency

during my child’s time with the JMPF/SPC/BBC.

4. I hereby expressly and specifically assume the risk of injury, illness death or property damage resulting

from the activities of my time with the JMPF/SPC/BBC.

5. Photographic Release. I grant and convey unto the JMPF/SPC/BBC right title, and interest in any and all

photographic images and video or audio recordings made by the JMPF/SPC/BBC during my child’s

participation at the JMPF/SPC/BBC, including, but not limited to, any royalties, proceeds, or other benefits

derived from such photographs or recordings.

6. Other. I expressly agree that thus Release is intended to be as broad and inclusive as permitted by the

laws if the state of Mississippi in the United States if America, and that this Release shall be governed by

and interpreted in accordance with the laws of the State of Mississippi. I agree that in the event that any

clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the

invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release,

which shall continue to be enforceable.