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After School Tutoring Starts September 10th.
About After School Tutoring
Our school-age program is the perfect place for children (6 to age 12) to end their day strong. Give them a smart start with our support and see them thrive! We keep students energized after class with:healthy snacks, Bible devotion, fun games and creative play, plus space to work on homework and lots of learning activities!
After School Tutoring Information
Start Time: 3pm-5pm. Location: City Lights Community Center (910 Palmer Ln)
Today's Date
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Child's Name
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First Name
Last Name
Date of Birth
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Current Age of child
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Address
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Will your child need transportation to and from After School Tutoring? (Please note - transportation is only available for specific areas in the city.)
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Yes
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Which bus stop location will your child be picked up from?
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Piedmont Circle
Skyline Village Apartments
Colony Place Apartments
Cleveland Homes
Hutton St. Apartments
Parent/Guardian Information
1st Parent/Guardian Name:
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Parent/Guardian Phone Number
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Parent/Guardians Email
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2nd Parent/Guardian Name:
Parent/Guardian Phone Number
Parent/Guardians Email
Emergency Contact:
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Relationship:
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Phone Number:
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Please enter a valid phone number.
Safety and Medical Information
Name and Phone number of person(s) other than parents allowed to pick up your child:
List names of any specific persons who are NOT authorized to pick up your child:
Add any special instructions, such as custody or restraining orders must be added to this application and discussed. Please list any other information you'd like to include about your child:
Allergies: (Food, Medication, Insect, or Other)
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Does your child have an Epi-pen? If yes, your child must provide Bright Start Early Learning with an Epi-pen to be kept at Bright Start during your child's enrollment. Epi-pen must be accompanied with a current prescription and a doctor's note.
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Yes
No
Please describe any specific activities to be restricted for any health reasons:
Authorization and Signature
Read all paragraphs carefully sign your name after each one.
Child's Name:
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Today's Date
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I give City Lights Ministry permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at City Lights Ministry and can be used for promotional purposes without notification.
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I give permission to City Lights Ministry and its staff to pick up and drop off my child(ren) to and from After School Tutoring. I will waive all liability and will not hold City Lights Ministry, its staff, or volunteers responsible for any accidents resulting from transportation or any activity at City Lights Ministry
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I give permission for City Lights Ministry to transport my child off property for the purpose of field trips and/or medical care. I understand that a schedule of events will be available to me and that all events are subject to change due to weather and/or scheduling conflicts without notice.
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Yes
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I authorize City Lights Ministry management to act as the agent of the parents in any emergency situation or to administer basic first aid for the health and welfare of the child involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for persons requesting exemption from medical treatment.
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Yes
No
In the event of a medical emergency, please list preferred hospital
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By signing below I agree to adhere to all the Policies and Procedures set for by City Lights Ministry’s Bright Start Early Learning Program.
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Submit
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