MIS Summer Camp Application

My Intentional Success
Date Received by MIS ____________
Student Information
Full Name:
Date of Birth:
Name preferred to be called:
This section to be completed by potential MIS student:
Circle any and all items that interest you:
Technical work of radio show
On air work of radio show
Graphic design
Website design
Writing for magazine
Photography for magazine
Community service
Leadership skills
Gold and Silver
Real Estate
Improved Learning Skills
Money management
Career preparation
College savings
College preparation
Business Development
Which weeks do you wish to attend camp (please circle all that apply):
June 1st-5th Start-Up Week
June 8th-12th Marketing
June 15th-19th Sales
June 22nd– 26th Investing
Medical Information
Are there any allergies or medical conditions that we need to accommodate?
If yes, please describe:
Parent/Guardian Information
Enrolling Parent’s Full Name:
Percentage of time that student resides at this address:
Home phone:
Work phone:
Cell phone:
Email address:
Other children from the household are also in or applying for the program:
Second Parent/Guardian Information
(required for separated or divorced parents with shared parenting time that coincides with Program hours)
Second Parent’s Full Name:
Percentage of time that student resides at this address:
Home phone:
Work phone:
Cell phone:
Email address:
Emergency Contact
If there is an emergency and we cannot contact Parent or Second Parent, who should we contact?
Phone number:
Relationship to the student:
Permission for Others to Pick Up Student
The following people are allowed to pick up the student in my absence:
Relationship to student:
Relationship to student:
Relationship to student:
Payment Information
Each week of camp is $199
If you choose to do multiple weeks there are breaks in the price.
2 weeks for $383 (save $15)
3 weeks for $567 (save $30)
All 4 weeks for $699 (save $97)
This section is not mandatory to complete if paying by check.
This form shall serve as written authorization for My Intentional Success to utilize the credit card account listed below for
payment. Please run my credit card for the amount indicated below, and I agree to make payment, based on the terms of the issuing bank(s).
Name of Cardholder:
Billing Address:
I hereby authorize My Intentional Success to Charge $99 on the below credit card on a One-Time Basis for my child’s enrollment
and materials fee for one semester.
Cardholder Signature
Card Number:
CVV Code:
Amount to charge: $199 for 1-week of entrepreneur camp
$383 for 2-weeks of entrepreneur camp
$567 for 3-weeks of entrepreneur camp
$699 for 4-weeks of entrepreneur camp
Application Process
Students apply for the My Intentional Success program with the support and consent from their parent(s). The director of the My
Intentional Success facility where the student would participate in the program reviews the applications and selects students to
participate in classes of up to sixteen students, based on relative age and experience, interests, and schedule availability. My
Intentional Success will notify the student and parent(s) when the student is selected for MIS Entrepreneur Camp(s). Parent(s) will
have five business days to sign the Program Agreement and make a payment of $100 to secure the student’s spot in that camp.
The remaining balance must be paid by June 1st, 2015. Once the student’s enrollment has been confirmed into one or more weeks
of camp, My Intentional Success will send student and parent(s) further details regarding that specific class session information.
Selection Criteria
Students are selected based on their attitude, motivation, willingness, and drive. If a student is not selected for inclusion in the
program, My Intentional Success encourages the student to reapply next year/semester.
No Discrimination
My Intentional Success does not select students on the basis of gender, race, religion, national origin, or any other categorical
I have read the Values of the Program and the Honor Code in the Program Agreement, and if accepted into the program, I agree to
be bound by them. This can be found at www.myintentionalsuccess.com or you may request a copy.
I understand the commitment required of this program and if accepted into the program, I will honor that commitment.
Student Signature
I have read the My Intentional Success Summer Camp Agreement and if student is accepted into the program, I(we) agree to
execute the Agreement and be bound by it.
If accepted into the My Intentional Success program, I(we) give permission for Student to participate in offsite events and
If accepted into the My Intentional Success program, I(we) agree to support and facilitate student’s participation in the program
and to provide transportation when needed so that student can fulfill their commitment to this program.
Parent/Guardian Signature
Second Parent/Guardian Signature
You may sign and date, scan and email to [email protected]
Or fax to
Or drop off at
My Intentional Success
13413 Frankford Ave, unit 4
Lubbock, TX 79424
If you have any questions, please call 806-577-7217 or email us at [email protected]