BCHS - Barren Beyond the Bell Registration
Please complete registration form for the 2020-2021 school year. Registration MUST be on file in order to participate in any before or after school activity.
Email address *
Student Name: First, Middle Initial and Last *
Address: Street, City, State and Zip Code *
Grade - Choose 1 *
Student Date of Birth: *
Gender *
Lunch Status - Please choose 1 *
Ethnicity - Please choose 1 *
Primary Language - Choose 1 *
Student Lives With (Please Choose 1): *
Activity student is interested in (please check all that apply): *
Are you interested in participating in morning (before school) hours or afternoon (after school) hours? *
Will your child be attending an "extended library session" in the library beginning at 6:45 AM? *
Will your child attend an afternoon session? *
If your child will attend an afternoon session, please choose a pick up time that best suits your needs. *
Are you interested in virtual programming for your child/ren? i.e tutoring, camps, etc. *
Special needs (i.e. medications, allergies, diet, etc): *
Parent/ Guardian 1 Name: (First, Middle Initial and Last): *
Parent/Guardian 1 Relationship: *
Parent/Guardian 1 - Best Phone Number for Contact *
Parent/Guardian 2 Name (First, Middle Initial, Last):
Parent/Guardian 2 Relationship:
Clear selection
Parent/Guardian 2 - Best phone number for contact:
ADDITIONAL CONTACTS: List additional contacts for student. Please include Name (First and Last), Address, and a good phone number for each contact. Also, please indicate if these individuals are authorized to pick up the student and/or will serve as an emergency contact.  If no adults are listed below, ONLY THE PARENT(S)/GUARDIAN(S) WILL be able to pick up the student(s). ***There must be a minimum of 2 adult contacts for student*** *
Are there any legal restrictions in effect preventing certain individuals from seeing and/or picking up student? If yes, please indicate the person/s name below. If no, please answer no and continue on. ***Please note that our school will need legal documents in order to enforce the no contact*** *
Please read each of the following statements and check the box next to each to consent for 21st CCLC participation: *
By typing your name below you are certifying that you have read and understand the above agreement and are authorized to sign for the mentioned student to participate in the BCHS Barren Beyond the Bell 21st CCLC after-school program. *
A copy of your responses will be emailed to the address you provided.
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