SGBA SUMMER 2023

Summer Grove Baptist Academy Summer Program
Date Registered

MonthDayYear
Date
Week of: June 12: July 3: June 19:July 10: June 26:July 17: Summer Program is for 6 weeks Monday - Thursday from 9:00 - 2:00

Ages 6 mo. - 3rd Grade (Completed) June (paid in advance): $285 July (paid in advance): $285 June & July (paid in advance): $550 Weekly Cost: $100 Session Fees are NON-REFUNDABLE
WEEKS:

June 12June 19June 26July 3July 10July 17
# of Weeks per Child
Name of Child
Date of Birth
Age
Grade
Name of Child
Date of Birth
Age
Grade
Name of Child
Date of Birth
Age
Grade
Best person and phone number to contact while child is in our care:
Home Address
City
State
Zip Code
Mother's Name
Mother's Cell #:
Mother's Email:
Mother's Work #:
Father's Name
Father's Cell #
Father's Email
example@example.com
Father's Work #
Are you a member of SGBC?

YesNo
If no, are you a member of another church? If yes, where?
List 2 people & their relationship to the child who might be called in an emergency if parents cannot be reached.
Name
Phone #
Name
Phone #
Name of people other than parents who have permission to pick up the child.
1
2
3
Do any of the children have allergies?

YesNo
If yes, please list child's name, allergies, and symptoms below.
Anything special we should know about the child?
Parent Signature

Clear
Should be Empty: