BCASP Registration Form

Burch Creek After School Program

APPLICATION 2018-2019

Current Date: ______________________                                                            Tuition Amount ______________

 

Student Name

Sex: [M/F]

Date of Birth

Age

Grade

Teacher

Ethnicity*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*(WH) White (BL) Black (HI)Hispanic (AS) Asian (AI) American Indian

 

First Parent (Guardian):

Name: ________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: ____________________________ State: _________________________ Zip: ________________________________________

Home Phone #: (____) ________________ Work Phone #: (____) __________________ Cell Phone #: (____) __________________

Email address:                                                                                                                                

Employer Name: _____________________________________________________________________________________________

Address: ______________________________________ City: _____________________ State: ______________ Zip: ____________

Reference Source:  How did you hear about our program? _________________________________________________________________________________________________________________________________________________________________________

Second Parent (Guardian):

Name: ______________________________________________________________________________________________________

Address (if different from Parent 1): ______________________________________________________________________________

City: ____________________________ State: _________________________ Zip: _________________________

Home Phone #: (____) ________________ Work Phone #: (____) __________________ Cell Phone #: (____) __________________

Email Address:                                                                                                                        

Employer Name: _____________________________________________________________________________________________

Address: ______________________________________ City: _____________________ State: ______________ Zip: ____________

 

Medical Emergency:  If emergency medical treatment is deemed necessary and the parent or guardian cannot be contacted, authorization to the BCASP Staff will be given to act in parent’s behalf granting permission for the child to receive emergency treatment.

Physician: _____________________________________ Phone #: (____) ________________________________________________

Address: _____________________________ City: ___________________State: ___________________ Zip: ___________________

Preferred Hospital: ____________________________________________________________________________________________

Insurance Provider: _____________________________ Policy #: ________________________ Phone #: (____) ________________­

Please list any allergies or health problems your child may have that our staff should be aware of: _________________________________________________________________________________________________________________________________________

 

Persons Authorized to pick up child/children from BCASP, and also to contact in case of emergency or illness, when parents or guardian are not available.

Name                                                                                       Phone (during program hours)                              Relationship

______________________________                  ____________________________                     ________________

______________________________                  ____________________________                     ________________

______________________________                  ____________________________                     ________________

______________________________                  ____________________________                     ________________

 

 

I give my permission for my child to attend BCASP. (Burch Creek After School Program) I release BCASP from any liability. 

I understand that it is my responsibility to arrange transportation for my child/children after the program daily at a specified time.  I understand there are late fees that apply if I am late picking up my child/children.  I support the efforts of BCASP staff in caring for my child/children.  I understand that my child must abide by the discipline procedures established by BCASP, and also the discipline code set up by the Weber School District, and if these are not followed, my child may be dismissed from the program.  I understand my child’s grades may be reviewed to help monitor his/her progress and to assess the program.  I also allow the program to access information from the school regarding my child’s lunch status for snack and tuition purposes.  All information will be kept confidential.  I understand that tuition fees are to be paid prior to my child’s attendance in BCASP.

 

Parent’s Agreement Signature _______________________________________________________Date__________________________

 

I agree to uphold and support all rules and guidelines established by BCASP in order to provide a safe and fun environment for all participants. I understand if I do not follow the guidelines specified, I will be dismissed from the program.

 

_____________________________________________________________________________

Student’s Agreement Signature

 

 

Acceptance into the Program is based on Approval.

(You will be notified in writing or by phone if your child/children have been accepted)