Please complete this form filling any unanswered questions with N/A.  Thanks for sharing your child with us!
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Child's Last Name *
Child's First Name *
Child's Date of Birth
Parent(s)/Guardian(s) Names *
Cell Phone *
Home Phone *
Work/ Other Phone *
Home Address and Mailing Address (if different from home) *
Parent(s)/Guardian(s) Email *
Child's Email (if applicable) *
Emergency Contact(s) and phone number *
Person(s) allowed to pick up student *
Current Grade Level *
What school or preschool does your child attend? *
Does your child have any medical or physical conditions, allergies, or anything that we need to be aware of or that may hinder him/her from fully participating in any activities? *
Please explain in detail below
MEDICAL RELEASE: The Breakthrough Fellowship its directors, officers, employees, owners and agents are hereby released of any and all liability for accidents, injuries, or other damages arising from my child's participation in the BT KIDS programs. In the event of a life threatening injury or illness, I authorize The Breakthrough Fellowship to take my child to the nearest medical center or hospital for treatment. *
Please type your initials and date below.  Your signature will be required on a separate document.
PHOTO & PRESS RELEASE: The Breakthrough Fellowship reserves the right to use images and like forms of images of all persons enrolled in BT KIDS This is at the sole discretion of The Breakthrough Fellowship.  Images compiled will be used in Public Relations, Marketing, Advertisement, and other media.  By initialing below I give  The Breakthrough Fellowship permission to use images of my child for the previous mentioned uses-Only to be used in conjunction with The Breakthrough Fellowship. *
Please type your initials below. Your signature will be required on a separate document.
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