Thank you for your interest in participating in the MDTMT program. Please complete the application.  We'll be in contact with you to inform you about the status of your application upon submission.

Name *
Name
Address *
Address
Phone 1 *
Phone 1
Enter your child's best contact number.
Mother's Name *
Mother's Name
Mother's Telephone Number *
Mother's Telephone Number
Father's Name
Father's Name
Father's Telephone Number
Father's Telephone Number
Emergency Contact
Emergency Contact
Emergency Contact Number *
Emergency Contact Number
Health/Medical Information
Enter the name of your family doctor/pediatrician or the name of the medical office.
Family Doctor/Pediatrician Phone Number *
Family Doctor/Pediatrician Phone Number
Date Of Last Tetanus Immunization
Date Of Last Tetanus Immunization
If yes, please provide details of the conditions and management procedures.
Emergency Consent *
In the case of an emergency or extreme circumstances is there any medication that you give consent to the leaders to responsibly administer?
Getting To Know You
Write a paragraph about who you are, what you enjoy doing, and your favorite things.
Please list at least three reasons you'd like to join our program.
Parent information
Please describe your applicant, let us know of any specific areas you'd like us to focus on with him, and why you believe he needs to be in participate in MDTMT's program.
PLEASE BE CERTAIN THAT YOUR ANSWERS ARE TRUE AND CORRECT BEFORE CLICKING THE SUBMIT BUTTON. *
By submitting this application you also agree to give your child permission to attend off-site field trips and you give consent for your child's image to be published in any print, photographic, video, web or other media (including the MDTMT website).