MANHOOD BOOT CAMP CONSENT FORM
c/o Winsome Ministries, Inc. * P.O. Box 124 * Perrineville, NJ 08535
(732) 887-0010 (mobile) * e-mail: sistaphyl@yahoo.com
For completion by authorized client only.
I have read, understood, and do comply with the aforementioned principles, purposes, and $1,500.00 payment for this program entitled Manhood Boot Camp.
My signature confirms my agreement:
______________________________ ___________________
Principal or authorized Faculty member Date
Specified dates of program (monthly
□ weekly □ bi-weekly□) School year:__________________________________________ ___________________________
______________________________ ___________________________
______________________________ ___________________________
Amount received: $ ___________Balance due, if any: $__________
Method of payment:
cash: (not recommended)
check number: ___
money order: ____
credit card: *AMEX q Discover q VISA q MasterCard q Otherq
Card number: ________________________________ Exp. Date: ________
*CID code (front):_____ All other cards: CCV2 code ( back): ________
Signature: ____________________________________________________
_____________________________________________________________
White copy: Winsome Ministries, Inc. * Pink copy: School office * Yellow copy: School tax records
RECLAIM * MOTIVATE * PRESERVE