STARS Application Fall 2022

STARS After School Program: Fall 2022

Register by Sept 1-Begins Week of September 5
Register for Ballet, Jazz and/or Hip Hop classes here!

Register for Golf Squad here!

(Other classes listed at the bottom of the form)
I. Enrollment Information:
Parent First Name *
Parent Last Name *
Primary Phone Number *
Primary E-mail Address *
Child First Name #1 *
Child Last Name #1 *
Birth Date *

Month Day Year
Grade *
Gender *

Male Female
T-Shirt Size *
Please list here if child has any allergies or medical concerns:

Click to register multiple children...
Child First Name #2
Child Last Name #2
Birth Date

Month Day Year
Grade
Gender

Male Female
Please list here if child has any allergies or medical concerns:
Child First Name #3
Child Last Name #3
Birth Date

Month Day Year
Grade
Gender

Male Female
Please list here if child has any allergies or medical concerns:

Section Stopper

Select Class(es): Please also add your selections to your cart when checking out. *

	Child #1	Child #2	Child #3
Cooking Club
Run Club (K5-5th)
Art (K5-5th)

MEDICAL CONSENT: BCS - STARS 2022-2023

As parent(s) or legal guardian(s), we hereby give permission for our child(ren), as named above, to participate in Beaches Chapel School's STARS program and activities.

I, and my child, do hereby release, forever discharge, and agree to hold harmless Beaches Chapel Church and School and the directors, employees, its agents and all other persons associated with Beaches Chapel S.T.A.R.S., from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned (and the participant, if a minor) while said persons are in the care of Beaches Chapel S.T.A.R.S. or its leaders.

I understand that, in the event my child requires medical or dental treatment while engaged in the activity, reasonable efforts will be made to contact me. However, if I cannot be reached, I hereby consent and give permission to Beaches Chapel S.T.A.R.S. leaders, or any adult leader acting on behalf of S.T.A.R.S., to act as an agent for me. They may consent to any treatment and care advised and supervised by a physician, surgeon, or dentist in an emergency.

In the event of the necessity of the administration of first aid and/or a doctor’s care, or any other form of medical treatment necessitated by illness or injury, the undersigned agrees to hold harmless and indemnify said church, it’s directors, employees, agents, and all other persons associated with Beaches Chapel S.T.A.R.S. from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

PHOTOGRAPHIC RELEASE:I authorize Beaches Chapel Church and School, or anyone authorized by Beaches Chapel Church and School, to use and reproduce any and all audio and video tapes and photographs which Beaches Chapel takes of my child or any family members produced for the school web site, literature, advertisements, and promotional purposes, without any compensation.

DISCIPLINARY POLICY: We strive to make STARS classes a positive experience for all students who participate. If a child’s actions negatively affect the STARS instructor’s ability to teach the course, the student with be involuntary withdrawn from the class. A written warning will be given before being asked to withdraw from the class. If your child is involuntarily withdrawn from the course, you will not be reimbursed.

CLASS CANCELLATION POLICY: If fewer than three students register for a STARS class, the class will be cancelled and parents will be given the option to switch to another STARS class or receive a refund for the course.
Class Schedule:

Monday

Cheer: K5-5th (Sanctuary)

Tuesday

Golf: K5-5th (Field)
Hip Hop: K5-5th (Multi-Purpose Room)

Wednesday

Ballet/Jazz: K5-5th (Multi-Purpose)

Thursday

Volleyball: 3rd-5th (Field/Sanctuary/Impact Center)

Pickleball: 2nd-5th (Jarboe Park)
PHOTOGRAPHIC RELEASE: Please check one:

Yes No
I hereby certify that I am a parent/guardian of
(Child/ren's Name/s)
I have read this release and waiver of liability, fully understand it’s terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be complete and unconditional release of all liability to the greatest extent allowed by law.
Parent/ Guardian Signature:
Date

Month Day Year
II. If Child is NOT a current BCS student, please click "Click to fill out section". Otherwise, skip to Financial Contract section.

Click to fill out section.
Name of Health Insurance Policy Holder

First Name Last Name
Name of Insurance Co.
Policy No.
Child's Family Doctor
Phone Number

Area Code Phone Number
Child's Family Dentist
Phone Number

Area Code Phone Number
My child has the following medical or health problems:
Current Medications:
Parent(s) Name:
Parental Marital Status:
Student Resides With:
If Guardian, List Relationship:
Street Address:
City, State, Zip:
Home Number

Area Code Phone Number
Dad's Cell Phone

Area Code Phone Number
Mom's Cell Phone

Area Code Phone Number
E-mail
Other persons authorized by parent or guardian to take child from the facility or contact in emergency.
If none, please indicate:

None Other
Name:
Relationship:
Cell Phone

Area Code Phone Number

III. Financial Contract Information:

ANNUAL one time registration fee of $30 due per family with registration.

I understand that I am obligated to pay for the entire session whether student(s) attends or not.
Responsible Party's Signature: *
Use code "20OFF" when you register the same child in 2 classes per week!

Use code "40OFF" when you register the same child in 3 or more classes!

(Offer not valid for Golf, CDA classes or Pickle Ball)
Registration Fee

$30
Discounts

$20 off when you sign up for 2 classes per week, per child $40 off when you sign up for 3 or more classes per week, per child
Employee Discount

Employee Discount taken off at checkout
Subtotal:

STARS Payment Total

Registration Fee $ 30

Annual Fee

Cheerleading $ 250

K5-5th Grade 12 Weeks

Child	Quantity
Child #1
Child #2
Child #3

Volleyball $ 250

3rd-5th Grade 12 Weeks

Child	Quantity
Child #1
Child #2
Child #3

Pickleball $ 250

2nd-5th Grade 12 Weeks

Child	Quantity
Child #1
Child #2
Child #3

Enter coupon

Total $ 0.00

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STARS After School Program: Fall 2022