Summer Enrichment Program Registration - Southside Baptist Church

Registration Application
PROGRAM INFORMATION
- Program Dates: June 10th - July 3rd, 2019 from 8am-2pm.
- There is a registration cutoff of 40 paid participants. Afterwards, all other applicants will be placed on a waiting list. Should a child be unavailable to attend we will choose the next applicant off the waiting list.
- Each program day begins at 8:30 am and ends at 2:00pm.
- Breakfast and Lunch will be served each day during the program.
- Each Friday, students will be offered the offered the opportunity to discover different disciplines and in a safe, encouraging environments. This will be accomplished through field trips and career exploration activities.
Email Address of Registrant*
example@example.com
How many children are you registering?*
First Child
Child's Name*

First NameLast Name
Child Gender*

MaleFemale
Child's Birth Date*

MonthDayYear
Child's Age*
Last Grade Completed*
Child's T-Shirt Size*

Youth Small (YS)Youth Medium (YM)Youth Large (YL)Adult Small (AS)Adult Medium (AM)
Medical or other information we may need to know about the child (including food allergies).
Second Child
Child's Name*

First NameLast Name
Child Gender*

MaleFemale
Child's Birth Date*

MonthDayYear
Child's Age*
Last Grade Completed*
Child's T-Shirt Size*

Youth Small (YS)Youth Medium (YM)Youth Large (YL)Adult Small (AS)Adult Medium (AM)
Medical or other information we may need to know about the child (including food allergies).
Third Child
Child's Name*

First NameLast Name
Child Gender*

MaleFemale
Child's Birth Date*

MonthDayYear
Child's Age*
Last Grade Completed*
Child's T-Shirt Size*

Youth Small (YS)Youth Medium (YM)Youth Large (YL)Adult Small (AS)Adult Medium (AM)
Medical or other information we may need to know about the child (including food allergies).
Fourth Child
Child's Name*

First NameLast Name
Child Gender*

MaleFemale
Child's Birth Date*

MonthDayYear
Child's Age*
Last Grade Completed*
Child's T-Shirt Size*

Youth Small (YS)Youth Medium (YM)Youth Large (YL)Adult Small (AS)Adult Medium (AM)
Medical or other information we may need to know about the child (including food allergies).
Parent/Guardian & Emergency Contact Information
Parent/Legal Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Emergency Contact Information

Provide the names & numbers of persons to which the child(ren) may be released to each day after camp (Please provide at least two)
Emergency Contact 1 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 1 Phone Number*

Area CodePhone Number
Emergency Contact 2 (other than parent/guardian listed above)*

First NameLast Name
Emergency Contact 2 Phone Number*

Area CodePhone Number
Emergency Contact 3 (other than parent/guardian listed above)

First NameLast Name
Emergency Contact 3 Phone Number

Area CodePhone Number
Emergency Contact 4 (other than parent/guardian listed above)

First NameLast Name
Emergency Contact 4 Phone Number

Area CodePhone Number
Child Pick-Up Information
Names of Persons to which the child (children) may be released to each day after Summer Enrichment (Please provide at least two)*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Full Name*

First NameLast Name
Cell Phone Number*

Area CodePhone Number
Full Name

First NameLast Name
Cell Phone Number

Area CodePhone Number
Full Name

First NameLast Name
Cell Phone Number

Area CodePhone Number
Are there any persons to which the child (children) may NOT be released to?*

YesNo
Who may you child (children) NOT be released to?
Include Persons' Name and Relation to the Student
Program Release Information
MEDIA RELEASE INFORMATION - By checking the box below, I hereby give permission for photographs and/or video in which my child appears in to be used by the church in printed and/or electronic media, including the church's website and social media platforms.*

Yes, I give permission.NO, I do not give permission.
RULES & CODE OF CONDUCT

The goal of our Summer Enrichment is to build up students in our community by equipping them adequate educational and enrichment experiences so that they can fulfill their God-given purpose, and bring hope to their family, friends and peers. Therefore, we act in accordance with our faith and our vision.

Rules
1. Obey leaders always. No back talking.
2. Participate in all classes and activities.
3. Take care of the all the property of the church.
4. Do not use ANY bad language.
5. Always go to class on time. Bathroom breaks are between classes.
6. No fighting or instigating fights. The church needs to be a place of peace.
7. Please dress modestly when attending church events.
8. Attendance is IMPORTANT! Please be here as many days as possible.
General Consequences for Rule-Breaking
- First Occurrence: Student will receive a verbal warning from the leader or assisting adult in the group.
- Second Occurrence: Student will be removed from group by an assisting adult. A private discussion should resolve the problem and the student may return to activity.
- Third Occurrence: The student will be removed from group by an assisting adult. The student’s parent will be notified of their behavior as quickly as possible. Resolution of the issue will be affected by the student, parents and leader(s) prior to the student returning to activities.
- Fourth Occurrence: Repetitive breaking of the offense will result in disciplinary action (ranging from performing service duties to student suspension) for the student. If the student refuses to perform the task(s) asked of him or her, a suspension will be served immediately. No refunds will be issued regardless of participation.
I have read and understand the Rules and Code of Conduct.*

YES, I have read and understand the rules and code of conduct.NO, I have NOT read and DO NOT understand the rules and code of conduct.
Payment Information
The cost of our Summer Enrichment Program is $30 per child. Payment must be made before your child(ren) can participate in the program. Payment can be made at the Southside Baptist Church administrative office by exact cash, check (addressed to Southside Baptist Church), or money order. Payment Deadline: Monday, June 10th, 2019.
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Registration Application

First Child

Second Child

Third Child

Fourth Child

Parent/Guardian & Emergency Contact Information

Child Pick-Up Information

Program Release Information

Payment Information