MTC Registration | Mulerider Kids College | Southern Arkansas University

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Mulerider Teen College

A debit or credit card is required to complete registration online. If you do not have a debit or credit card to pay online please contact Anne Sands at 870-235-4357.

Student Information

Name*

First Last

Grade (entering into next year)*

Age*

Date of Birth*

School Attended*

Race*

*Race and gender information are used for grant reporting purposes only.

Gender*

Did you receive a scholarship from Magnolia Public Schools?*

Yes

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Are you applying for a SAU scholarship?

Yes

Please check all that apply to your family:*

Free School Lunch

Reduced School Lunch

SNAP Benefits

Medical Assistance

Other, please describe below.

Explanation and/or other information

Did this child receive a MKC or MTC scholarship last year?*

Yes

Scholarship policy

Scholarships will be given based on need until funding is no longer available. Only one scholarship may be given per child. All scholarship applicants will be notified by April 29th. Your child’s schedule will be held until April 30th. If you do not receive a scholarship you will have until May 6th to make payment arrangements or your child’s schedule will be dropped.

Please verify that you have read the scholarship policy.*

I have read and understand the above policy.

Parent or Guardian Information

Name*

First Last

Email*

Home Phone

Work Phone

Cell Phone

Mailing Address*

Street City State ZIP Code

Emergency Contact Information

Please list two people who can be contacted in the case of an emergency if parent/guardian cannot be reached.

Name*

First Last

Phone*

Name*

First Last

Phone*

Please list up to two people that will be responsible for picking up your child each day.

Name

Relationship

Allergy/Medical History

Please list any known allergies or significant medical history.

Doctor

Name Phone Number

Medical Release

If I cannot be reached to make plans for emergency medical care for my child, I give my permission to SAU and its representatives to take my child to Magnolia Regional Medical Center.

• I give my permission to use photography, videotape, and/or audiotape in which my child may appear in SAU marketing and publicity.
• I understand that SAU is not responsible for any personal items (i.e. games, money, clothing) brought to the facilities. I understand that my child should not bring a cell phone, tablet, or any other electronic device to camp.
• I have discussed appropriate behavior with my child and am aware that inappropriate behavior will result in dismissal from the program without the benefit of refunded tuition.
• In the event my child suffers minor scrapes, bruises, or injuries I give permission for my child to be treated at University Health Services at SAU.

Waiver of liability

This release and waiver of liability executed this date by the undersigned, parent of __, is granted to Southern Arkansas University In consideration of the opportunity to participate in Teen College, that receipt of this benefit is hereby acknowledged, releasor voluntarily and knowingly executes this release and waiver of liability for any injury of the minor child resulting from participating in the activities of the SAU sponsored Teen College. This trip is a voluntary activity for the child.

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Waiver signature

Name*

First Last

Entering your name in the fields above will act as your electronic signature.

T-Shirts

T-shirt Size*

One t-shirt is included in tuition fee. Students must wear their shirts everyday!

Would you like to purchase additional shirts?*

Yes

How many additional shirts would you like to purchase? *

Price: $10.00

Additional shirt sizes and quantities*

Shirt Size

Quantity

To buy additional shirts in more than one size click the plus icon to add a new row.

Tuition

Tuition is $75 per student for the week.

Class Choices

For MTC - Your child will enroll in three classes. Class placement will be first come, first serve so please register as soon as possible.

MTC - First Period*

MTC - Second Period*

MTC - Third Period*

MTC - Fourth Period*

Payment

Mulerider Teen College Registration

Price:

Scholarship Discount

Price: -$60.00

Scholarship deadline is April 19th. Only one $75 scholarship may be given per child. All scholarship applicants will be notified by April 20th. Your child’s schedule will be held until April 27th. If you do not receive a scholarship you will have until April 27th to make payment arrangements or your child’s schedule will be dropped.

Coupon(s)

Code must be in ALL CAPS. You may enter and apply multiple coupons.

Total

If your total is $0, please do not enter your credit card information below.

Credit Card

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Final Schedules and detailed camp information will be EMAILED to all registrants after May 18th.

If you prefer to have your schedule mailed to you please let us know below.

DO NOT email - please mail a copy to me instead.

Email a copy of my child's schedule.

Please click submit just once and wait for the page to load. Repeated clicking could result in duplicate registrations and charges.

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Transaction ID

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Description

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Code

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Date

Mulerider Kids College

Mulerider Teen College

Student Information

Scholarship policy

Parent or Guardian Information

Emergency Contact Information

Allergy/Medical History

Medical Release

Waiver of liability

Waiver signature

T-Shirts

Tuition

Class Choices

Payment

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