After School Program Enrollment Form

Bedazzle The Youth Program Enrollment Form

2023-2024
Bedazzle the Youth Program is dedicated to fostering creativity, volunteerism, and childcare services in youth through our fun and engaging summer program. Our 8-week program is designed to provide a safe and creative environment and features an easy online enrollment process. This summer program is funded by donors, sponsors, and grant funding. The program begins June 1, 2024, and ends July 31, 2024

Please complete and submit one form per student/child enrolled in the Bedazzle The Youth Program Summer Program.
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
Student's Name*

First NameLast Name
Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 10Grade 11Grade 12
Effective date for enrollment in Bedazzle The Youth Program*

MonthDayYear
Please indicate the month and day that this agreement is to take effect. For example, if you will be using the Summer Program from the first day of the program, enter 06-03-2024.
MondayTuesdayWednesdayThursdayFriday
Please indicate your child's default dismissal plan:
MondayTuesdayWednesdayThursdayFriday
MondayTuesdayWednesdayThursdayFriday
Please note any known allergies:
Please specify each person, including the name of parents, who has permission to pick up your child from the After School Program.
Authorized Person 1:

First NameLast Name
Driver License Number Phone Number 1:

Drivers License NumberPhone Number
Authorized Person 2:

First NameLast Name
Driver License Number Phone Number 1:

Drivers License NumberPhone Number
Authorized Person 3:

First NameLast Name
Driver License Number Phone Number 1:

Drivers License NumberPhone Number
Authorized Person 4:

First NameLast Name
Driver License Number Phone Number 1:

Drivers License NumberPhone Number
Statement of Policy

(Must read and acknowledge)
- Only persons authorized by the parent or guardian may pick up their child from the Summer program. Please notify the Director in writing if anyone other than a parent/guardian will pick up your child. (Must include first and last name, phone number, and driver's license number.)
- All students attending the Summer Program are required to follow all program rules. Behavioral problems will result in parent notification and possible suspension from the program.
- Students with a fever or contagious illness may not participate in the program.
- This program is available for all students, grades 1st - 8th.
- The 8-week Summer Program runs from June 1, 2024 – July 31, 2024.
- Time 8 am to 5 pm
- Child pick up no later than 6 pm
- An Enrollment Form is required for all students participating in this program.
- This is a free summer program.
Agree
Signature

Clear
Should be Empty:

Bedazzle The Youth Program Enrollment Form

Statement of Policy