PALS Summer Registration Form

PALS Summer Registration Form

Summer 2025
The $35 registration fee must be paid by cash or check within one week of your child being placed in a class. You will be notified via email of acceptance.
In Session Dates:

May 27, 28,29

June 9, 10, 11, 12

June 16, 17, 18, 19

June 23, 24, 25, 26
July 7, 8, 9, 10

July 14, 15, 16, 17

July 21, 22, 23, 24

July 28, 29, 30, 31
*We will offer "in-school" field trips as well as other special activites during the summer for our older classes (3 & up). Extra actvities may require a minimal fee to participate - children will not be required to participate.
Student Name

First NameMiddle NameLast Name
Name Child Goes By

Name
Birth Date

MonthDayYear
Gender
Registration (please select one)

1 day $1252 days $2453 days $3404 days $410
Day(s) your child will attend: *we are closed on Fridays during the summer program*
Early Care (7:00 AM-8:00 AM):

1-2 days $353-4 days $45
Late Care (2:30 PM - 4:00 PM):

1-2 days $453-4 days $60
Mother/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Mobile Number
Employer
Work Number
Father/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Mobile Number
Employer
Work Number
Parent/Guardian with Legal Custody:
Parents are:
Child Lives With:

Medical Consent and Emergency Form Summer 2025
In the event child's name becomes ill or sustains an injury while participating in the PALS program of First Baptist Church Hartselle, AL, I, the undersigned parent/guardian, give my permission to those in charge to take whatever steps are necessary to stop bleeding and to administer first aid, including emergency transportation if I cannot be reached immediately.

I also consent to an x-ray examination, anesthesia, medical or dental or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervision, and upon the advice of a duly licensed physician and/or surgeon. I agree to be responsible for any medical expenses incurred.

If parent/guardian refuses to sign, instructions must be attached stating what procedure the program is to follow in an emergency.
Any special health concerns, or health/medical instructions? Is your child enrolled in therapy?
What medications does your child take?
Please list all allergies & reactions (also include if your child has an EpiPen):
Regular doctor & phone number:
Insurance carrier & policy:
Person authorized to act for parent in case of an emergency:
Name, relation & phone number

Media Release
The undersigned parent/legal guardian hereby gives permission to PALS for child's name
to be photographed and/or videoed for internal use.to appear on FBCH/PALS social media platforms.to appear on the FBCH/PALS website.
Signature

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Pick-up Authorization Form
Please list all persons authorized to pick-up your child from PALS. Any person picking up your child must be on this list. Siblings under the age of 16 may not pick-up your child from PALS.*
Should be Empty:

Medical Consent and Emergency Form Summer 2025