Extend Program Registration Form
First Baptist Church School

First Baptist Church
Beeville, Texas

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EXTENDED PROGRAM REGISTRATION FORM

Child's Name:   ____________________________________________________________________
                 Last First MI Name called

Residence Address:
_________________________________________________________________

Mailing  Address:
__________________________________________________________________

Parent's Name(s):
___________________________________________________________________

Home Phone _______________ Work Phone________________________

List below the person or persons authorized to pick up your child in case you cannot.

1. __________________________________________________________________
            (Name)                                     (Address)                                     (Phone #)

2. ________________________________________________________________
         (Name)                                                         (Address)                                 (Phone #)

Teacher/Grade
________________________________________________________________

Special lnterests:
________________________________________________________________

Please check the program desired:
________Morning only                                __________Afternoons only
________ Both A.M. & P.M.                          ___________Drop-ln only

MEDICAL RELEASE

In the event I cannot be reached to make arrangements for emergency medical treatment or illness or injury, I hereby authorize the extended care person or other qualified person in charge to take my child to Dr. ______________ Phone #___________________________ or if not available, to the hospital emergency room.

 Parent's Signature______________________________________

  Remarks: Special diet, food  allergies, etc.)

End of Form