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.
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I understand and accept this information
Student Information
Let us know who your child is!
Student Name
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First Name
Last Name
Gender
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Female
Male
Birthdate
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Month
-
Day
Year
Date
Date Picker Icon
Age
School Attending:
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Riser Middle
Riser Elem
Lenwil Elem
Boley Elem(Pending)
Grade 2019-2020
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Ethnicity
Caucasian
African American
American Indian
Hispanic/Latino
Asian
T-shirt Size
Youth Small
Youth Medium
Youth Large
Youth XLarge
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Parent/Guardian Information
Parent/Guardian Name
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First Name
Last Name
Relationship to the Child
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Father/Mother
Aunt/Uncle
Grandmother/Grandfather
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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
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Area Code
Phone Number
Home Phone
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Area Code
Phone Number
Cell Phone
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-
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?
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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
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First Name
Last Name
Relation to the Child
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Emergency Contact 1 Phone Number
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Area Code
Phone Number
Emergency Contact 2
First Name
Last Name
Relation to the Child
Emergency Contact 2 Phone Number
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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
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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?
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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.?
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Yes
No
Doctor Name
First Name
Last Name
Doctor Phone Number
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Area Code
Phone Number
Dentist Name
First Name
Last Name
Dentist Phone Number
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Area Code
Phone Number
Is your student currently taking medication for any mental or emotional condition?
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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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