The Piney Woods School
Changing the World…One Student At A Time!
SUMMER
YOUTH
LEADERSHIP
INSTITUTES
2015
P.O. Box 99
Piney Woods, MS 39148
601.845.2214, ext 2216
601.845.2604 fax
e-mail: [email protected]
web site: www.pineywoods.org
Table of Contents
I. Introduction ----------------------------------------------------------
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II. Fall School Enrollment --------------------------------------------
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III. About Piney Woods------------------------------------------------1. Mission Statement-------------------------------------------------------2. Student Body-------------------------------- ---------------------------3. Curriculum-------------------------------------- ------------------------4. Christian Education -----------------------------------------------------5. The Work Program ------------------------------------------------------6. Other Offerings -----------------------------------------------------------
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IV. Summer Youth Leadership Institutes Schedule
Academic Leadership Classes
1. STEM Combo--------------------------------------------------------------- 2. Agri-business ------------------------------------------------------------------3. Career Planning / College Prep ------------------------------------------4. Comprehensive Reading and Analytical Thinking ---------------Afternoon Leadership Workshops / Speaker Series
1. Civil Rights / Social Justice -------------------------------------------2. Teamwork/Team Building---------------------------------------------3. Entrepreneurship Sports Business------------------------------------4. Health/Medical / Law---------------------------------------------------5. Professional Arts --------------------------------------------------------Afternoon Leadership Activities
1. Beginning Swimming --------------------------------------------------2. Sportsmanship / Piney Plays ------------------------------------------3. The Art of Fishing-------------------------------------------------------4. Indoor Recreation -------------------------------------------------------5. Golf ------------------------------------------------------------------------6. Creative Arts --------------------------------------------------------------
VI.
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V. Question and answers about Piney Woods School’s Summer Youth Leadership Institutes
1. When does the camp begin and end? --------------------------------7
2. What do I need to know about registration? -----------------------7
3. How old must a student be to attend camp? ------------------------7
4. What does a typical camper’s day look like? ----------------------7
5. What will campers be required to wear? ----------------------------7
6. Is Sunday chapel attendance required for all campers? ----------8
7. What is the dress code? ------------------------------------------------8
8. What else should campers bring besides uniforms? --------------8
9. What if my child gets sick or has an accident? --------------------8
10. What else is needed to assure my child’s acceptance? -----------8
11. What are your disciplinary practices?---------- ---------------------8
12. How will my child get to the campus?----------------------------8
13. Tell me about the instructors and counselors of the
Summer Enrichment Camp --------------------------------------------9
14. What is the cost to attend the camp?---------------------------------10
15. Where should I send my registration form and other
papers, and who should I call if I have any questions? ----------11
Forms
1. Summer Camp Application/Reservations --------------------------12
2. Method of Payment – Form A ----------------------------------------13
2. Medical Consent – Form B --------------------------------------------14
3. Health History – Form C -----------------------------------------------15
4. Leave Authorization – Form D ---------------------------------------16
5. Authorization to Attend Events/Media Release – Form E ------17
Introduction
Enrichment programs are vital to the social development of our youth. Since 1986 The Piney
Woods School has offered a Summer Enrichment Camp that has provided students with the
opportunity to acquire skills through intensive learning workshops. But, as the world changes
so do our youth. This year we have revamped our Summer Camp experience to include a more
leadership focus. We will offer an enriching learning experience as we introduce our Summer
Youth Leadership Institutes with the primary objectives to:
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Expose students to various leadership workshops that instill the motivation to seek higher
levels of achievement and learn the value and importance of a sense of community.
Provide scholastic activities based on the changing paradigm of our workforce.
Expose students to educational activities rich in cultural information and experiences.
Develop students’ reading, writing, and speaking skills while involved in each camp.
Provide introductory experiences that focus on science, technology and engineering.
Allow campers to be socially introduced to peers from around the world in a structured,
safe environment.
Provide a Christian atmosphere for human growth and development, character education,
and citizenship in an ethical environment.
Work, fun, and more all take places within a safe country setting located in the piney woods of
Mississippi.
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Fall School Enrollment
Attendance at The Piney Woods School’s Summer Enrichment Camp also provides
an opportunity for potential students to experience the school’s environment and
programs prior to regular school enrollment. If you are interested in your child
attending The Piney Woods School in the fall, applying early is crucial, as
residential space is limited. Students must meet admission criteria prior to
acceptance. We seek to admit students in grades 9-11 who have demonstrated a
commitment to getting a good education.
Call or write for your application packet at the following address:
The Piney Woods School
Office of Admissions
P. O. Box 57
Piney Woods, MS 39148
(601) 845-2214, ext. 2223
or e-mail us at:
[email protected]
or download and print at:
www.pineywoods.org
(click on ADMISSIONS)
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About The Piney Woods School
Founded in 1909 by Laurence Clifton Jones, The Piney Woods School is one of only four
historically black boarding schools remaining in the United States. It is a school rich in history
and cultural activities, while at the same time keeping abreast of the latest program trends that
can improve achievement for its historically African-American student body.
The Piney Woods School recognizes that throughout the United States there are students,
especially African-American students, who have the capability to make their lives extraordinary
through excellence in education and the development of moral and ethical attitudes but do not
have the opportunity to do so for financial or other reasons.
Piney Woods School’s mission is to provide that excellence in education within a Christian
community through creation of an exceptional academic model which supports the tenet that all
students can learn, develop a strong work ethic, and lead extraordinary lives through academic
achievement and responsible citizenship.
Mission Statement
The Piney Woods School recognizes that throughout the United States there are students,
especially African-American students, who have the capability to make their lives extraordinary
through excellence in education and the development of moral and ethical attitudes but do not
have the opportunity to do so for financial or other reasons. Piney Woods School’s mission is to
provide that excellence in education within a Christian community through creation of an
exceptional academic model which supports the tenet that all students can learn, develop a
strong work ethic, and lead extraordinary lives through academic achievement and responsible
citizenship
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Student Body
Piney Woods School students have the opportunity to interact with students from across the
United States, the U.S. Virgin Islands, as well as with students from other countries including
Ethiopia, South Africa, Nigeria, and Cameroon. We serve students in grades 9-12.
Curriculum
We have a strong college-prep curriculum. Science and mathematics are a major focus of the
curriculum, with requirements in these exceeding those of the accrediting agencies.
Christian Education
Christian Education is a component of the school program where students learn about the
Christian religion and have the opportunity to participate in Bible study as well as Sunday
School and church services.
The Work Program
The work program continues to be a vital part of the school’s operation. All students must work
on campus to help defray the cost of their tuition. No student will be allowed to remain at the
school who refuses to do his/her assigned work.
Other Offerings
We offer an environment conducive to learning which will also prepare students for higher
educational opportunities and quality living. We have small class sizes, an excellent college
placement program, and high expectations for students. The campus has a beautiful country
setting with five lakes, a farm, baseball and soccer fields, basketball and tennis courts, and a
swimming pool. We offer financial aid and scholarships to students who meet the criteria. Our
admissions are selective.
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The Summer Youth Leadership Institute Schedule
Academic Leadership Classes
(8:00 AM – 11:50)
Students will rotate; between the classes outlined below.
1. STEM Combo
Campers will be involved in collaborative, hands-on classroom workshop experiences that will
help develop vital skills needed as an engineer: creativity, goal-setting, communication and time
manage-ment. They will explore and discover the full potential of their imagination and creativity
by putting together bridges with the use of balsa wood.
2. Agri-business
Through various hands-on and interactive activities, campers will learn about the nature of
agribusiness, career opportunities in agribusiness how to determine supply and demand for
products and export/import activities in agribusiness. The campers will also develop a business
plan related to the field of agriculture.
3. Career Planning / College Prep
This camp is designed to instruct students in a group and allows the instructor the opportunity to
monitor and assist students as individuals. Students read to one another, check comprehension,
practice spelling, and assist in editing each other’s writing through peer review. Rewards and
certificates are based on individual and team performance.
4. Comprehensive Reading and Analytical Thinking
Campers will explore methods and techniques in reading through personal interest materials. They
will use the reading and writing lab to receive instruction through audio tutorial, computer
assistance, and directed reading while gaining a greater appreciation for reading.
Afternoon Leadership Workshops/Speaker Series
(1:00 – 3:00)
Students will rotate; being introduced to one leadership workshop daily as outlined below.
5. Civil Rights / Social Justice
 Campers will learn History regarding the Civil Rights era.
 Will discuss current events
 Participate in inactive discussions on social justice
 Will engage in activities regarding legal issues and rights
6. Teamwork/Team Building
 Campers will participate in fun engaging activities regarding how to work with others
 How to collaborate and communicate with their peers
 How to effectively handle conflict resolution
7. Entrepreneurship Sports Business
 Learn how to create business plans
 Learn the importance of Financial Planning
 Be introduced to Entrepreneurship in related fields
 Glimpse into the world of Sports and Entertainment agents in the USA
8. Health/Medical / Law
 Learn about related field and how to become leaders.
 Learn the art of Debates and participate in-house legal debate
 Introduced to these particular professionals
 Healthy Eating – Healthy Habits: Learn the importance of taking responsibilities of one’s health.
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9. Professional Arts
 Learn basic techniques of acting
 Participate in an interactive session in Theatre / Dance
 Campers will learn beginner techniques in play writing
 Campers will learn various aspects of Performing Arts.
Afternoon Activities
(3:15 – 5:00)
Students will rotate; engage in one activity daily as outlined below.
10. Beginning Swimming
Campers will learn about:
 Swimming as a recreational and utilitarian activity.
 Basic skills required for beginning swimming and diving.
 Observing safety procedures.
 Artificial respiration techniques.
11. Sportsmanship/Piney Plays
Campers will be introduced to various games focused on sportsmanship on and off the floor. They will
learn the rules of the games and how they are played.
12. The Art of Fishing
Campers have an opportunity to connect with the outdoors and get excited about the environment as
they work through hands-on lesson plans that teaches fishing techniques, terminology, tying flies and
jigs and aspects of marine biology.
13. Indoor Recreation
The Recreation Department has many activities to offer for campers. Our recreation program is
structured to meet the needs of all campers involved. We offer billiards, ping pong, air hockey, video
games, table games, cards, checkers, chess, backgammon, and many other board games that advocate
appropriate social behaviors.
14. Golf
Campers will be introduced to the technical, pre-competition and competition phases of instruction by
focusing on all aspects of the swing (short game to full swing), multiple rounds, and course
management strategy sessions.
15. Creative Arts
Course will include:
 Drawing and Painting – developing the use of paints and inks from natural materials on the site;
 Paper Making and Decorating – developing the preparation of paper from natural vegetation on
site, and manufacturing it into useful products (cards, wrapping paper, etc.);
 Batik – developing the use of natural dyes from vegetation on site.
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Questions And Answers
About Our Summer Youth Leadership Institute
1. When does the camp begin and end?
The Piney Woods School will host two Summer Youth Institutes:
Female Summer Youth Leadership Institute
Begins on June 15, 2015, and officially ends at 12:00 noon on June 26, 2015.
* The residence halls will open at 8:00 a.m. on Sunday, June 14, 2015.
Residence halls will close at 12:00 noon on Saturday, June 27, 2015.
Male Summer Youth Leadership Institute
Begins on July 13, 2015, and officially ends at 12:00 noon on July 24, 2015.
* The residence halls will open at 8:00 a.m. on Sunday, July 12, 2014.
Residence halls will close at 12:00 noon on Saturday, July 25, 2014.
2. What do I need to know about registration?
Girls Summer Youth Leadership Institute
Registration will be held on Sunday, June 14, 2015.
Boys Summer Youth Leadership Institute
Registration will be held on Sunday, July 12, 2015.
All campers must report to The Piney Woods School’s Chandler Auditorium for camp registration on the date indicated above.
Registration is required of all campers and will be held between the hours of 8:30 a.m. - 5:00 p.m. Resident hall assignments will
be made and uniforms will be issued at this time. Room assignments will be made within the resident halls.
3. How old must a student be to attend camp?
All campers must be between the ages of 12 and 15, and cannot be less than 12 or more than 15 as of July 14th.
4. What does a typical camper’s day look like?
From Monday through Friday, campers will begin their day with a wholesome breakfast and then attend their
scheduled enrichment camps.
Weekends will include large group functions and social activities, with Sunday set aside for attending chapel service,
resting, and participating in other recreational activities.
5. What will campers be required to wear?
Two gold, regulation PWS T-shirts are included in camp fees. Additional T-shirts can be purchased, if available, at
the following costs:
(s-m-l)
$ 12.00
(xl-xxl-xxxl)
$ 15.00
NOTE: Campers must bring at least three pairs of solid black shorts (no more than two inches above or below the
knee). SAGGING PANTS WILL NOT BE ALLOWED!
Full dress requirements are:
 Regulation solid black shorts —boys and girls (no more than two inches above or below the knee)
 Regulation PWS T-shirt
 Tennis shoes for daily wear
 Dress or skirt and blouse for Sunday (girls)
 Dress pants and shirt with tie for Sunday (boys)
 Dress shoes for Sunday
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
White or black socks—boys and girls (socks must be worn daily)
Black or dark brown belt (boys and girls)
6. Is Sunday chapel attendance required?
Yes. Campers will be required to attend Sunday services on June 20, 2015 for the girls and July 18, 2015 for
the boys.
7. What is the dress code?
All Students Must:
 Have their hair combed neatly daily.
 Look neat while out on campus grounds.
 Not wear plastic hair covers, rollers, or bed clothing outside of the dormitory.
 Be dressed or in a bathrobe while in the dormitory doorways, hallways, lounge, windows, or in view from
the outside.
 Wear cap bibs to the front.
 Not wear caps or hats inside buildings.
 Dress appropriately. No bare midriffs or unbuttoned shirts or blouses that expose the chest area are
permitted.
 Wear regulation summer camp attire unless otherwise specified.
 Dress appropriately for campus socials. Skirts/dresses are to be worn at proper lengths and be free of
long splits. No clothing is to be tight fitting, exposing, or sagging.
 Wear moderate swimwear (girls must wear one-piece bathing suits only; boys must wear jams only.)
Girls
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Boys
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
Earrings are to be no longer than one inch in length.
Colored nail polish is not allowed (only clear).
Skirts and shorts are to be worn within the bounds of propriety.
Earrings cannot be worn.
No sagging pants or shorts allowed.
8. What else should campers bring besides uniforms?
A.
B.
C.
D.
E.
Bookbag, no. 2 pencils, notebook paper, pens, dictionary, etc.
Sunday School clothing (see question #7), a Bible, and dress shoes
Sleepwear
Pillow, bed linen, blankets, and mattress cover/pad
Long handle combination or bike chain combo lock and a neck key chain (students are
encouraged to keep their valuables* locked away.)
F. Toothbrush, toothpaste, deodorant, hair care products, towels, etc.
G. Bathrobe, slippers/shower shoes, one-piece bathing suits (for girls), swim trunks (for boys),
raincoat/umbrella
H. Spending money
* To prevent items from being lost or stolen, we recommend that expensive items be left at home: such as jewelry,
headphones, electronic device, including cell phones, ipods, mp3s, tablets, laptop computers, cameras, psps,
headphones, etc.
9. What if my child gets sick or has an accident?
If your child gets sick or has an accident during camp, he/she will receive medical attention from the school’s nurse or
school doctor. If it is necessary for your child to receive medical attention off campus, the parent will be
responsible for ALL medical expenses and/or prescribed medications. In order to obtain off-campus medical
service for your child, we will need to have the following information on file:
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A. Signed and notarized medical consent form from parent(s) (see forms in the back of this booklet.)
B. Copy of insurance/Medicaid card
C. Important health information on special diets, asthma, allergies, hyperactivity, heart condition, epilepsy,
blood type, etc.
Important:
Doctors and/or hospitals may refuse treatment of camper without a notarized MEDICAL CONSENT FORM signed by
parent(s) or guardian(s).
10.
What else is needed to assure my child’s acceptance?
Be sure to complete and return all the requested forms in this booklet. All fees must be paid in full on or before
Tuesday, June 10, 2014. Early payment will help to assure camp admission for your child. The camp fee is $500.
11.
What are your disciplinary practices?
PLEASE READ THIS SECTION CAREFULLY!
Disciplinary practices hold the best interest of the camper and school in mind. Campers will be expected to follow
all school rules and regulations. They will be provided with an orientation session and a camper handbook. It is
important to note that school policies on discipline may include one or more of the following, depending on the
offense:
1. Expulsion (fighting, possessing drugs and/or weapons, insubordination, breaking rules repeatedly,
breaking the law)
2. Work duty (dining hall, paper detail, etc.)
3. Social probation (cannot attend social activities)
4. Other methods will be used depending on the offense
Summer campers are expected to abide by the school’s policy in regard to drug and alcohol use. Summer campers
are, therefore, subject to testing if school officials have reasonable suspicion of drug and/or alcohol use. If the test
proves positive, the summer camper may be suspended for the remainder of the Summer Enrichment Camp. The
parents/guardians will receive no refund of fees.
12.
How will my child get to the campus?
Our transportation policy for summer campers is as follows:
A. We provide transportation to and from the AIRPORT as well as the BUS and TRAIN stations
from JACKSON, MISSISSIPPI, ONLY between the hours of 6:00 a.m. until 10 p.m. If you
wish for your child(ren) to arrive or depart from another city or place, it will be your
responsibility to make ALL of the arrangements for getting them to and from The Piney Woods
School.
B. For safety reasons and identification purposes, we must have a photograph of your child.
13.
Tell me about the instructors and counselors of The Summer Youth Leadership Institute.
We hire competent, qualified instructors. All instructors bring a wealth of knowledge and experience to
the program. The teaching staff consists of Piney Woods School instructors as well as instructors from the
public school systems.
Camp counselors are usually college students who are assigned to a small group of students and will be
responsible for their overall chaperoning, care, and guidance. All counselors go through training prior to
working with students.
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The nurse, doctor, camp coordinator, administrators, school counselors, and dormitory parents will also be
available to help make summer camp a successful and happy experience.
14. What is the cost to attend the camp?
All fees include two regulation camp T-shirts (one gold; one white):
Two-week Session
$500
*** Scholarships are available on case by case biases***
There will be no reimbursements or refunds.
15. Where should I send my registration form, payment, and other papers, and who should I call if I
have any questions?
The Piney Woods School
The Summer Youth Leadership Institute
P.O. Box 99
Piney Woods, MS 39148
Katrina Mclin, Summer Youth Leadership Institute Director
(601) 845-2214, ext. 2216
e-mail
[email protected]
The deadline for
submitting all forms and fees is:
June 10, 2014 (Girls)
July 08, 2014 (Boys)
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The Summer Youth Leadership Forms
In order to ensure your child’s acceptance, the forms on the following pages must
be completed in their entirety and mailed to:
The Piney Woods School
P.O. Box 99
Piney Woods, MS 39148
Attn: Summer Youth Leadership Institute
Katrina McLin
NOTE: Incomplete forms will delay the application process.
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THE
PINEY
WOODS
SCHOOL
Summer Youth Leadership Institute
Application
Thank you for your interest in our Summer Youth Leadership Institute. Our Campers will be exposed to various
speaker series (workshops) on Leadership (Health/Medical Careers, Teamwork/Teambuilding, Civil Rights,
Entrepreneurship/Sports Business, and Performing Arts/Acting) that will be lead by local and national known
mentors,
a host fieldtrips and so much more …….
Girls (June 15 – June 26, 2015)
Boys (July 13- July 24, 2015)
Today’s Date
Student’s Name
Age
Social Security #
Date of
Birth
Address
P.O. Box/ Street
City
State
Zip
City
State
Zip
Parent/Legal Guardian (responsible for student while at camp)
Name
Address
P.O. Box/ Street
Where you can be reached:
Home
(
)
Cell
(
)
Work
(
)
E-Mail
Applications will be accepted until April 30, 2015. Camp *fee of $500 and 1 letter of
recommendation (from teacher, counselor, Pastor, etc.) is due before May 31, 2015.
Email [email protected] or call 601-845-2214 ext. 2216
for more information.
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Form A
The Piney Woods School
Method of Payment Form
To reserve a space for my child
(Camper’s Name)
Two –Week session (boarding)
I am enclosing:
$500.00
1 Letter of Recommendation
Fees can be paid with cash, cashier’s check, credit card (Visa, Master Card, Discover, and
American Express), money order, or personal check (pending approval via Telecheck)
METHOD OF PAYMENT
Cashier’s Check
Visa
Personal Check (must be approved via Telecheck)
American Express
Discover
Money Order
MasterCard
Credit Card Number
Signature of Cardholder
Expiration Date
Cardholder’s Zip Code
**Cash will only be received if paying in person**
How did you hear about our Summer
Youth Leadership Institute?
I have read the entire camp brochure and understand it. My child and I agree to abide by the guidelines governing this
program.
Signature of Parent / Legal Guardian
Date
PRINTED NAME of Parent / Legal Guardian
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Form B
The Piney Woods School
Medical Consent Form
In consideration of the agreement by The Piney Woods School to admit
_______________________________________ as a student (social security number: __________________),
the undersigned parent/legal guardian hereby authorizes The Piney Woods School and its agents and employees
to secure for the above-named student any medical, mental health, or dental treatment which they, in their sole
judgment, may deem necessary and proper for said student. We further specifically authorize The Piney Woods
School and its agents and employees to execute administration of any medical, mental, or dental treatment or
procedure whatsoever to said student. We also authorize Century Life Insurance Company (or any successor
company) to pay directly to The Piney Wood School all benefits that become payable.
We hereby release and waive any claims for damages which we or the said student might have against The
Piney Woods School or its agents or employees in any manner arising from or in the course of medical, mental
health, or dental treatment or procedure administered to said student.
We, individually and on behalf of the student, do hereby release, acquit, and forever waive and discharge the
said Piney Woods School and Century Life Insurance Company (or any successor company) and their agents
and employees from any and all action claims for compensation on account of personal injuries from instances
occurring while the student is enrolled at The Piney Woods School. We, the parent/guardian, will take sole
responsibility for any bills incurred which are not covered by insurance. This form also authorizes the release of
information pertinent to the treatment of this child.
Parent/Guardian:
Address:
*Insurance Carrier:
Address:
City
State
Zip
City
Home Number
State
Zip
Policy / Medicaid
No.:
Claim Service #:
Work Number
Signature of Parent/Legal Guardian
Signature of Student
Sworn and subscribed before me this ______day of ____________of 20______in __________________________
County and State of ______________________.
Notary Public
(seal)
Date Commission Expire
THIS FORM MUST BE NOTARIZED.
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*Copy of insurance card (front & back) must be provided*
Form C
The Piney Woods School
Health History
The following information is absolutely necessary to your child’s health and well-being while attending The Piney Woods
School’s Summer Enrichment Camp.
Camper’s Name
Home Address
P.O. Box/ Street
City
State
Zip
Physician
Address
Phone Number
P.O. Box/ Street
(
)
City
State
Zip
--
In Case of Emergency Contact:
Name
Address
P.O. Box/ Street
City
State
Zip
P.O. Box/ Street
City
State
Zip
Relationship to Student
Name
Address
Relationship to Student
Health Problems: List any health problems that your child may have: (ex: asthma, allergies, heart condition, seizures, etc.)
List any medication(s) your child is presently taking:
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The application will not be processed unless a copy of the camper’s IMMUNIZATION FORM is attached to this sheet.
Form D
The Piney Woods School
Leave Authorization Form
In order to assure the safety of our summer campers related to leaving campus to travel home or elsewhere, we are asking
you to complete the following form. If you would like to change or add any names to this form, please contact the
academic office in writing.
Camper’s Name
Parent/Legal Guardian
Home Address
P.O. Box/ Street
City
State
Zip
Name of person(s) authorized to pick up the student(s). Please include complete address and telephone numbers.
1.
2.
Authorized Person Name
Address
Home Number
(
)
Cell Number
(
)
Work
(
)
E-Mail Address
(
)
City
State
Zip
P.O. Box/ Street
City
State
Zip
P.O. Box/ Street
City
State
Zip
Authorized Person Name
Address
3.
P.O. Box/ Street
Home Number
(
)
Cell Number
(
)
Work
(
)
E-Mail Address
(
)
Authorized Person Name
Address
Home Number
(
)
Cell Number
(
)
Work
(
)
E-Mail Address
(
)
__________________________________________
Signature of Parent/Legal Guardian
______________
Date
Sworn and subscribed before me this ______day of ____________of 20___in __________________________
County and State of _________________.
Notary Public
(seal)
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Date Commission Expire
THIS FORM MUST BE NOTARIZED.
Form E
The Piney Woods School
Authorization To Attend Events / Media Release
I hereby grant permission to The Piney Woods School for my child to:
1. Attend the following events, on or off campus, sponsored by The Piney Woods School: field trips (class),
athletic events, and special events (concerts, plays, park events, etc.),
2. Appear in or on the following medium: brochures, videos, newsletters, radio talk shows, television ads, etc., all of
which are used to promote the school. I understand that such promotions will be in keeping with the mission and
educational philosophy of The Piney Woods School, and that The Piney Woods School reserves the right to
utilize such material in current and future promotional projects.
Camper’s Name:
Date of Birth:
Home Address:
P.O. Box / Street
City
State
Zip
Telephone Number
Parent/Legal Guardian:
_______________________________________
Signature of Parent/Legal Guardian
_____________
Date
Sworn and subscribed before me this ______day of ____________of 20___in __________________________
County and State of _________________.
Notary Public
(seal)
Date Commission Expire
THIS FORM MUST BE NOTARIZED.
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