MBK Application Form

MBK Application Form

Summer Camp Registration Form Preview
MBK Application Form
  • My Brother's Keeper

    Greater Charleston

    Summer Camp - August 3-5, 2017


    Registration Form

    One form per participant
    Deadline July 21, 2017


    **You will need to download the Liability Waiver HERE and sign it. You MUST upload them at the end of this form.**

    Please use Google Chrome to translate to spanish and other languages as necessary. / Por favor utilizar Google Chrome para traducir al español u otros idiomas, según sea necesario.

  • Dear Parent/Guardian(s):


    Thank you for your interest in our 2017 MBK Charleston Summer Camp! The two day, fun-filled event is scheduled for August 3-5, 2017 at Charleston Southern University. The camp will provide mentoring, personal development and STEM enrichment for rising 7th, 8th, 9th & 10th grade boys of color. The program, as part of the National MBK initiative, aims to address persistent opportunity gaps faced by boys of color to ensure that all young people can reach their full potential.

    During the two-day event, participants will stay on campus for ONE NIGHT ONLY. (NOTE: Campers are REQUIRED to stay overnight, no exceptions!). All chaperones are required to complete a thorough background investigation.

    Over the course of the camp, participants will:

    • Tour the CSU campus
    • Participate in hands-on computer science and cyber security activities
    • Meet with college admissions advisors
    • Learn valuable interpersonal skills and techniques
    • Engage with a diverse group of mentors

    The boys should be dropped off at The Quads on August 3 at 9:00 a.m. Parking is available in the front of the dormitories. The boys will be picked up from the Dining Hall inside the Strom Thurmond Center on August 5 at 12:30 pm. with parking at the rear of the building. See Campus Map for the specific locations.


    All boys attending the camp are REQUIRED to have a least 1 parent/guardian present during the day camp on August 5th. On that day, the parent only session(s) will be conducted to walk parents/guardians through the process of preparing their child(ren) for college. NOTE: Parents should arrive promptly at 9:00 am on August 5th at the Dining Hall in the Strom Thurmond Center at Charleston Southern University.

    Transportation to and from the camp will be the responsibility of the parent/guardian. Parking is available throughout campus (Campus Map)
    While the 2017 MBK Charleston Summer Camp is a free event, space is limited. Students ARE NOT automatically admitted into the camp, but must apply. Upon completion and submittal of the application, the MBK Charleston Summer Camp committee will review and notify the applicant of their decision by July 28, 2017. A completed application file includes the following: Registration Form and uploaded Liability Waiver. All registrations forms must be completed and submitted online by July 21, 2017.

    NOTE: The use of cellphones are prohibited during the instructional portions of the camp. Your child(ren) will be required to leave his phone in his assigned room during the day. If you have an emergency, please contact one of the MBK Summer Camp Program Coordinators listed below.
    If you have any questions, feel free to contact Anishi Scott, Felicia Veasey, and/or Jenna Richardson. We sincerely hope you and your child(ren) will be able to attend this exciting event. We look forward to hearing from you soon!

    MBK Summer Program Coordinators,


    Anishi Scott, Jenna Richardson & Felicia Veasey

    FOR CAMP INFORMATION, FAQ's, and more, check out www.mbkgc.org/camp

    • CLICK HERE TO ENTER PARTICIPANT INFORMATION  
    • PARTICIPANT INFORMATION

    • CLICK HERE TO ENTER PARENT/GUARDIAN INFORMATION  
    • NOTE: All boys attending the camp are required to have at least 1 parent/guardian during the day camp on August 5th. Transporation to and from the camp will be the responsibility of the parent/guardian.

    • Parent/Guardian Information

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    • CLICK HERE TO ACKNOWLEDGE ANTI-BULLYING STATEMENT  
    • ANTI-BULLYING POLICY

    • Mission Statement:

      Everyone involved in the My Brother's Keeper Summer Camp is committed to making our camp a safe and caring place for all students. For that reason we prohibit harassment against students during the camp, including harassment based on real or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender (including gender identity and expression) and sex, and to prohibit discrimination based on these same characteristics. We will treat each other with respect, and we will refuse to tolerate bullying in any form.

      Our camp defines bullying as follows:

      It is our belief that “Bullying is participation in any intentional behavior that causes physical, emotional or social damage through the abuse of power.” This can be done either through physical size, social status, intelligence, or other factors that make the bully powerful. Bullying is unfair and one-sided. It happens when someone keeps hurting, frightening, threatening, teasing or leaving someone out on purpose.

      Examples of bullying include:

      • Hurting someone physically by hitting, kicking, tripping, pushing and so on.
      • Stealing or damaging another person’s things.
      • Ganging up on someone, touching, showing or making reference to private body parts.
      • Teasing someone in a hurtful way or spreading rumors about someone.
      • Using put-downs, such as insulting someone’s race or making fun of someone’s sex, hight, weight or wearing glasses, etc.
      • Leaving someone out on purpose or trying to get other kids not to play with someone.

      Our staff will do the following things to prevent bullying and help children feel safe during our camp:

      • Closely supervise students in all areas of the camp.
      • Watch for signs of bullying and stop it when it happens.
      • Respond quickly and sensitively to bullying reports using the following coaching model(The Four A-Response Process):
        • Affirm the child’s feelings, 2. Ask Questions, 2. Assess the child safety and 4. Act.
      • Take seriously students and parents’ concerns about bullying.
      • Look into all reported bullying incidents.
      • Assign appropriate consequences for bullying based on the school discipline code.

      Students at our camp will do the following things to prevent bullying:

      • Treat each other respectfully.
      • Refuse to bully others.
      • Refuse to let others be bullied.
      • Bystanders have a responsibility to assist victims in a variety of ways, including but not limited to the following:
        • Refuse to watch, laugh, or join in when someone is being bullied.
        • Try to include everyone in play, especially those who are often left out.
        • Report bullying to an adult.
        • Remove victim from bullying situation by inviting him/her to join a different activity with you.
        • Distract bully by inviting him/her to join you in a positive activity.

      Parents will do the following to prevent or address bullying:

      A. Parents will become integral members of the process in order to ensure a bully-free environment. When a child reports bullying, utilize the following coaching model (Four A-Response):

      1. Affirm the child’s feelings
      2. Ask questions.
      3. Assess the child’s safety.
      4. Act.

      B. In the event the camp personnel becomes aware that a child has engaged in bullying behaviors:

      • The parent of the child will be notified immediately.
      • Parent will be responsible for picking up the child immediately.
    • CLICK HERE TO ENTER AUTHORIZATION INFORMATION  
    • AUTHORIZATIONS & WAIVERS

    • EMERGENCY CONTACT & RELEASE AUTHORIZATION

      Please list in order additional names other than the parent/guardian listed above, 16 or older; that are authorized to be contacted in case of an emergency and allowed to pick-up the participant. Authorized indivduals will be required to show a picture ID. Please print all names.  

      Note: Camp staff will only allow the parent/guardian whose signature appears on this registration form to make changes to the form and staff will only release information about the participant to those person(s) listed.

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    • STUDENT PHOTO/VIDEO RELEASE

      MBK Sponsors / MBK Coalition

      MBK Sponsors and MBK Coalition Organizations may gather still image recordings (e.g., photographs), video recordings, or audio recordings highlighting a sponsored event and/or your child’s participation in this event.MBK Sponsors and MBK Coalition Organizations would very much appreciate permission to use your child’s name, likeness, voice, and/or interview in connection with this event, if necessary, for the purposes of highlighting this event in MBK Sponsors and MBK Coalition Organizations newsletters, web site postings, and other related communications.

      In consideration for being still image recorded (e.g., photographed), video recorded, or audio recorded or for attending this event, I grant permission for my child to be interviewed and/or recorded by an MBK Sponsors and MBK Coalition Organizations, and approve the use of such recordings in newsletters, web site postings and/or other related communications.

      As the parent/guardian, I affirm that I have the authority to grant permission under this agreement. I hereby relinquish any right to examine or approve the completed product. I fully understand the contents thereof.

    • CLICK HERE TO SUBMIT REGISTRATION FORM  
    • Click here to download Liability Waiver

    • By initialing in the box below, you agree to be present at the sessions from 9:00AM-1:30PM on Saturday, August 5th.

    • By initialing in the box below, you acknowledge: Cell Phones will remain in the boys room all day Friday. If there is an emergency and parents need to reach their child, they will need to contact Anishi Scott, Jenna Richardson or Felicia Veasey.

    • Clear
    • After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at CAMP@MBKGC.ORG


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