PB5 Registration Form SY22-23
                                                             Welcome to PB5  ------  Post Bell-5 days per week
                                                             Guntersville Middle School's after school program  

Please complete the registration form and submit.  A registration fee of $20 will be due upon the first day of attending the PB5 After School Program.  A weekly fee of $30 will be charged per student per week and payable on Friday of each week.  A drop-in rate of $10 per day is available.  This registration form must be on file before a student will be allowed to attend the program.  Please note:  ONLY the names of individuals listed on this form will be allowed to pick up your child from PB5.  Please add as many names/contact numbers as you think you will need.

Haley Thomason, 6th grade Science teacher, is the PB5 facilitator.
Her email address is: haleythomason@gcboe.net.  The phone number for the after school program is 256-558-3203
For further inquiries, please contact Julia Covington, Community Education Coordinator at 256-582-3159 or juliacovington@gcboe.net
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Student Name: *
Student Grade: *
Primary Contact Name: *
Primary Contact Phone Number(s): *
Primary Contact Email: *
In case of emergency, contact:  Include name and phone number(s) *
The following are allowed to check out/pick up my child from PB5:                                             Please provide name(s) and contact number(s). *
Does your child have any allergies that we should be aware of? *
If you answered yes, please indicate the allergy *
Do you give permission for your child to go on a field trip with the PB5 program either by school bus or on foot? *
Please mark your response regarding the fees associated with the PB5 program. *
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