Language
English (US)
After School Care
BEST Community Resource Center provides after-school care and out of school time programs for kindergarten through eighth grade. We provide safe, engaging, and meaningful extracurricular programs and activities to enrich the lives of students, give parents peace of mind, and assist teachers to focus on their academic mission. *Please Note: All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Student Information
Student Name
*
First Name
Middle Name
Last Name
Days you would like your child/ren to attend Program (select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
N/A
Grade Level
*
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
*
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Student Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
N/A
Grade Level
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Student Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
N/A
Grade Level
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Student Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
N/A
Grade Level
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Student Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
N/A
Grade Level
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Student Name
First Name
Middle Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
N/A
Grade Level
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6h Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Program Interest
Tutoring
Beauty Academy
Music
Arts
Gardening
Construction
Math
Literacy
Please select all that apply
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Information (1)
Parent Guardian (1) Name
*
First Name
Middle Name
Last Name
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Work Phone Number
*
-
Area Code
Phone Number
Parent/Guardian (1) E-mail
*
example@example.com
Address same as child?
*
Yes
No
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Parent/Guardian Information (2)
Parent Guardian (2) Name
First Name
Middle Name
Last Name
Cell Phone Number
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Parent/Guardian (2) E-mail
example@example.com
Address same as child?
Yes
No
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Health Information
Please fill out this form completely and accurately. If section does not apply to our child, please write “N/A”. ● IMMUNIZATION: I can provide my child’s immunization records and/or the records are on file at my child’s school. All required immunizations and/or tuberculosis test are current. ● AUTHORIZATION: In case of sickness or accident, I hereby give my permission to the medical personnel selected by BEST Community Resource Center to order and/or perform any medical attention deemed necessary, if I am unable to be contacted. I accept financial responsibility if such treatment is necessary. I further understand that neither BEST Community Resource Center nor its workers can be held responsible in the event of accident or accidental death.
Insurance Carrier
*
Member ID
Primary Care Physician Name
*
Primary Care Physician Phone Number
*
-
Area Code
Phone Number
Dentist Name
*
Dentist Phone Number
*
-
Area Code
Phone Number
Does the child have any allergies? If yes, list any food or drug allergies below.
*
Does the child have any medical conditions? If yes list any medical conditions below.
*
Does the child require any medication? If yes, please list these medications.
*
Do you authorize BEST Community Resource Center and our staff to administer the medications listed above?
Yes
No
Emergency Contacts & Authorized Pickup/Drop Off - Other than Parent/Guardian
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Photo/Video Release
I authorize BEST Community Resource Center to use photos/videos of my child for any legal use, including but not limited to publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Parent and Participant Statement of Agreement
● I understand that I may not leave my child at BEST Community Resource Center unless there is a staff member present. ● I understand that my child will not be allowed to leave the program with an unauthorized person or staff member. Only adults with valid photo IDs and who are over the age of 18 can be authorized to pick up the child. ● I understand that BEST Community Resource Center is mandated by Ohio Law to report any suspected cases of child abuse or neglect. ● I understand that I will be charged a late fee if I fail to pick up my child on time. ● I understand that BEST Community Resource Center staff may not baby-sit, transport, or care for children other than during the After-school program hours. ● I understand that my child may be removed from BEST Community Resource Center for any of the following reasons: 1) Failure to pay program fees by designated deadlines. 2) Inappropriate behavior of a child/parent that endangers anyone involved with BEST Community Resource Center. 3) Failure to observe any of the conditions listed in the Parent Handbook. *PLEASE NOTE: Failure to sign this parent agreement does not nullify this agreement
Statement of Responsibility
I understand and acknowledge that BEST Community Resource Center does not offer any medical insurance to protect against injuries, makes no claim to do so, and has no responsibility for any medical expenses incurred. I understand that each participant must assume the risk and any related financial responsibility that could result from participation in any of these activities. I agree to assume such risks and such financial responsibility.
BEST Community Resource Center Child Behavior Agreement
A Behavior Agreement is the first formal step to help solve repeated rule violations. This Agreement involves parents, child/ren, and staff. It requires participation of all parties. A sample contract is available at the Program Director’s office. A suspension may be necessary at the Program Director’s discretion. Upon continuous disciplinary problems, a child may be removed from the program indefinitely.
Receipt of Handbook
I UNDERSTAND AND ACKNOWLEDGE THAT I WILL RECEIVE A WRITTEN COPY OF THE BEST COMMUNITY RESOURCE CENTER PARENT HANDBOOK ON OR BEFORE THE FIRST DAY OF MY CHILD'S ENROLLMENT. THIS INFORMATION IS ALSO AVAILABLE AT WWW.BESTCOMMUNITYRESOURCECENTER.ORG
Parent/Guardian Signature
Clear
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