BMSSP Summer 2025 STEAM Registration Form

BMSSP Summer 2025 STEAM Registration Form

June 23- August 1, 2025
Please select the week(s) your child will have fun learning with us.*

All Six weeksJune 23-27June 30-July 3July 7-11July 14-18July 21-25July 28-August 1
Please select the type of day.*

regular day- 8:00 to 2:30 ($75/wk)extended day- 8:00 to 5:30 ($100/wk)
Student's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
T-shirt Size*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Caregiver Information
Primary Caregiver's Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact's Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Other than the primary caregiver and the emergency contact, who has permission to pick up your child from the program. Please provide their name and relationship to the child.*

School Information
School Name*
Grade in September*
School System*
Is there anything you would like to share about your child's academics?

Physical Health
Please select an option that best represents your child's physical health.*
Is your child currently under a physician's care?*
Physician's Name and Phone Number*
Insurance Provider and Policy Number*
Is your child currently taking any medication? (If yes, you will be required to complete a medication form.)*
Does your child have any allergies? (If yes, complete question below.)*
Does your child have a special diet? (If yes, complete question below)*
Is there anything we should know about your child's health?
Waiver
I the parent/legal guardian of the above student hereby consent to and grant permission for my child to participate in any and all activities of the Bethel Institute for Community Development (BICD) program including transportation to and from the activities.

The undersigned gives permission to BICD to use photographs and audio and/or video recordings of the Participant for fundraising and/or marketing purposes. On occasion, with permission, participant photographs may be included in promotional videos, websites, program brochures, newsletters, fundraising or flyers. BICD respects the privacy of its Participants and does not allow unauthorized visitors to photograph or video the camp or its Participants.

In consideration of my child being allowed to participate in BICD activities, I hereby forever release, acquit, discharge and covenant to hold harmless BICD, its officers, directors, trustees, employees, organizers, sponsors, and persons transporting my child to and from such activities, from any and all actions, causes of actions and claims of liability of any description growing out of, directly or indirectly, all known and unknown personal injuries or property damage, including but not limited to claims related to transportation, accommodations and/or activities in which my son or daughter may participate. This waiver covers all claims or causes of actions which I have as a parent of my child or which my child has or hereafter may acquire before or after she has reached her majority resulting from his or her participation in the BICD activities. I acknowledge that I am the parent or legal guardian of the child described above with legal authority to grant this consent/permission and waiver.
By typing my name, I am electronically signing this permission and waiver form. I agree to be bound by the electronic signature.*
Today's Date*
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BMSSP Summer 2025 STEAM Registration Form

Caregiver Information

School Information

Physical Health

Waiver