Broaden Horizons Afterschool 2019-2020 Application

Broaden Horizons Afterschool 2019-2020 Application

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

The BH Afterschool Program is a unique and enriching experience for your student. Our program runs Monday-Thursday 3:00-5:45 p.m. at Riser Middle, Riser Elementary, and Lenwil Elementary. 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, field trips, and more! Snack and a hot dinner meal will also be provided each day. Each campus is staffed with a Campus Coordinator, certified teachers, and college aged mentors who all strive to see your students "Loved, Educated, and Transformed" throughout the school year.
Completion of this form does NOT grant your student immediate acceptance into the BH Afterschool 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 Afterschool 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 Afterschool without having received a call from our office. *

I understand and accept this information
Student Information

Let us know who your child is!
Student Name *

First Name Last Name
Gender *

Female Male
Birthdate *

Month Day Year
Date Date Picker Icon
Age
School Attending: *
Grade 2019-2020 *
Ethnicity

Caucasian African American American Indian Hispanic/Latino Asian
T-shirt Size
Parent/Guardian Information
Parent/Guardian Name *

First Name Last Name
Relationship to the Child *

Father/Mother Aunt/Uncle Grandmother/Grandfather

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Total Number of persons living at address
Home Church, if any
Family Composition

Dual Parent (Both Mother and Father in Home) Single Mother Single Father Grandparent Other
Place of employment
Work Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Email
example@example.com
May we add your cell # to the BH “Remind” app so texts can be sent in case of emergency? *

Yes No
Does the child have a brother/sister in this program?

Yes No
Emergency Contacts

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

First Name Last Name
Relation to the Child *
Emergency Contact 1 Phone Number *

Area Code Phone Number
Emergency Contact 2

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

Area Code Phone 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 Name Last Name
Phone Number

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

First Name Last Name
Phone Number

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

First Name Last 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? *

Yes No
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 5:00 p.m.? *

Yes No
Doctor Name

First Name Last Name
Doctor Phone Number

Area Code Phone Number
Dentist Name

First Name Last Name
Dentist Phone Number

Area Code Phone Number
Is your student currently taking medication for any mental or emotional condition? *

Yes No
List all prescription medications
Student IEP/504 Plan in place?

Yes No
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.

Clicking here gives us your permission and is the equivalent of a signature.
I give permission to have my child’s grades, homeworklessons, standardized test results and any other performance relatedinformation released to Broaden Horizons After-School Program for purposes ofevaluating performance and measuring the child’s progress. This includes special education plans such asthe Individual Education Plan (IEP), 504 Plans and plans related to healthinformation, for the purposes of extending accommodations and modifications tothe after-school environment where applicable. There will be discussions from time-to-time with the child’s teachersand 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 andleaders.

Clicking here gives us your permission and is the equivalent of a signature.
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.

Clicking here gives us your child permission to participate in all Broaden Horizon Afterschool Program activities and is the equivalent of a signature.
I understand that my child’s participation in the Broaden Horizons Afterschool 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 Afterschool Program staff, teachers, and volunteers, Following the directions of the staff, teachers,and volunteers in the building and on the bus, 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 Afterschool Program Leadership. I agree to hold harmless Broaden Horizons Afterschool Program and First Baptist Church of West Monroe and any of their staff directors or employees in the event of an injury.

Clicking here gives us your child permission to participate in the Broaden Horizon Afterschool Program and is the equivalent of a signature.
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Broaden Horizons Afterschool 2019-2020 Application

About BH Afterschool Program

Student Information

Parent/Guardian Information

Emergency Contacts

Transportation

Medical Information

Parental/Guardian Consent