BH After-School 2026-27 Registration

Broaden Horizons After-School 2026-2027

Complete this application and we will be in contact with you about your student's enrollment!
About BH After-School Program

The BH After-School Program is a unique and enriching experience for your student. Our program serves Riser Elementary, Lenwil Elementary, and Riser Middle and runs Monday-Thursday 3:00-5:45 p.m. Students will experience the love of God and have access to extended learning experiences through enrichment activities, life skills, homework help, STEM activities, Bible studies, and more! Snack and a hot dinner meal will also be provided each day. Each campus is staffed with a Lead Teacher, certified teachers, and college-aged mentors who all strive to see your student "Loved, Educated, and Transformed" throughout the school year.
Start Dates: OPSB Schools will begin on Tuesday, September 8, 2026 and Minnie Ruffin will begin on Monday September, 14th

**Brief Parent Meeting at 5:30pm at your child's Broaden Horizons campus**
Completion of this form does NOT grant your student immediate acceptance into the BH After-School Program. We have limited spots available and accept students on a first-come-first-serve basis. We will contact you if your student has been accepted into the BH After-School Program. If all spots are filled, your student will be placed on the waiting list. As spots open, we will call those on the waiting list. Please do not send your student to BH After-School without having received a call from our office.
Student Information

Let us know who your child is!
Student Name

First NameLast Name
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
School Attending:
Grade 2026-27
Ethnicity

Other
T-shirt Size
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to the Child

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Total Number of persons living at address
Home Church, if any
Family Composition
Place of employment
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
May we add your cell # to "EZ Texting" so texts can be sent in case of emergency?
Does the child have a brother/sister in this program?
Emergency Contacts

Person to call in case of an emergency when you cannot be reached.
Emergency Contact 1

First NameLast Name
Relation to the Child
Emergency Contact 1 Phone Number

Area CodePhone Number
Emergency Contact 2

First NameLast Name
Relation to the Child
Emergency Contact 2 Phone Number

Area CodePhone Number
Transportation

You will be responsible for providing transportation for your student at the end of the day. Pick up is at 5:45 p.m.
1. Person that is allowed to pick up my student (other than myself)

First NameLast Name
Phone Number

Area CodePhone Number
Relation to the Child
2. Person that is allowed to pick up my student (other than myself)

First NameLast Name
Phone Number

Area CodePhone Number
Relation to the Child
Person that is NOT allowed to pick up my student

First NameLast Name
Relation to the Child
Medical Information

Does your child have medical issues we should know about?
Does your student have an allergy or condition?
If yes, please list
Does this allergy or condition require medication to be kept and/or administered between the hours of 3:00 p.m. to 5:45 p.m.?
Doctor Name

First NameLast Name
Doctor Phone Number

Area CodePhone Number
Dentist Name

First NameLast Name
Dentist Phone Number

Area CodePhone Number
Is your student currently taking medication for any mental or emotional condition?
List all prescription medications
Student IEP/504 Plan in place?
Parental/Guardian Consent

Please read and click the buttons below to finalize your registration.
I give First West, Broaden Horizons and its representative’s permission to use photographs, video, digital and/or other images that includes my child in any and all media products for promotion, art, advertising, editorial, or other purpose. This may include, but is not limited, to newsletters, both print and email, posters, brochures, ads, post cards, social media, and web pages. I understand that the interviews that he/she grants and the filming, photographs, or digital images may be disclosed to First Baptist Church of West Monroe and/or Broaden Horizons for the sole purpose of advertising, marketing or generally promoting the social service programs, activities, and work First Baptist Church of West Monroe and/or Broaden Horizons offers to the general public. This authorization will continue as long as the child is involved in Broaden Horizons. I understand that I have the right to revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. The authorization must be revoked in writing.
I give permission to have my child’s grades, homework lessons, standardized test results and any other performance related information released to Broaden Horizons After-School Program for purposes of evaluating performance and measuring the child’s progress. This includes special education plans such as the Individual Education Plan (IEP), 504 Plans and plans related to health information, for the purposes of extending accommodations and modifications to the after-school environment where applicable. There will be discussions from time-to-time with the child’s teachers and counselors in order to ensure that they are performing to their capability. As well, we will be an advocate for your child with school teachers and leaders.
I give my child permission to participate in the following: Field Trips throughout the year, character building, healthy relationships and life skills activities, Bible study, devotionals, and prayer time.
I understand that my child’s participation in the Broaden Horizons After-School Program depends upon his/her doing the following: Agree to have my child present 80% of the time or my child may be removed from the program, Completing all assignments and activities given to him /her by Broaden Horizons After-School Program staff, teachers, and volunteers, Following the directions of the staff, teachers, and volunteers, show the utmost respect to all staff, teachers, volunteers, guest, and other students. I understand that my child’s participation in the program depends upon my making sure that he/she follows the above instructions. I will inform my child’s teacher when he/she will be absent from the program for more than a week at a time. I understand that in order to better serve my family, a family needs assessment will be performed by the Broaden Horizons After-School Program Leadership. I agree to hold harmless Broaden Horizons After-School Program and First Baptist Church of West Monroe and any of their staff directors or employees in the event of an injury.
Should be Empty:

Broaden Horizons After-School 2026-2027

About BH After-School Program

Start Dates: OPSB Schools will begin on Tuesday, September 8, 2026 and Minnie Ruffin will begin on Monday September, 14th

Student Information

Parent/Guardian Information

Emergency Contacts

Transportation

Medical Information

Parental/Guardian Consent