Bee the Change Registration

Bee the Change Youth Enrichment Program

A T.C. Murdock Foundation Program
Program Operating Hours

Monday - Thursday

3:30 PM - 5:30 PM
**Transportation Disclaimer**

TRANSPORTATION IS NOT PROVIDED BY THE T.C. MURDOCK FOUNDATION, ALBANY LEADERSHIP CHARTER SCHOOL OR GRAND STREET COMMUNITY ARTS

Scholars who recieve bus transportation afterschool will be picked from Albany Leadership Charter Middle School at 4:00 PM. Transportation questions should be directed to the main office as transportation is not provided by the T.C. Murdock Foundation.

Scholars are welcome to stay for programing after 4:00 PM. Should your scholar stay after 4:00 PM a parent/gaurdian will be required to provide transportation for their scholar.
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
After-school Club Registration
Expected Start Date

MonthDayYear
School Attending
Grade Attending
Pick When
What days of the week are you looking for care?*
Student Information
First Name*
Last Name*
Student Grade
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care #*
Doctors Name*

First NameLast Name
Doctors Phone Number*

Area CodePhone Number
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
Is your child immunized?*

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Please list the people authorized to pick up your child.
Does your child have any siblings?*
If yes, what is their age(s)?
Comments
Are you signed for the T.C. Murdock Foundation e-newsletter?
To sign up for our E-Newsletter visit our website at www.tcmurdockfoundation1.org
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
By signing below you are giving your scholor permission to participate in the Bee the Change Youth Enrichment Club at Albany Leadership Charter School.
Signature

Clear
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
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Bee the Change Youth Enrichment Program

After-school Club Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian