ECA Program - Registration Form
At BSI, our vision for the ECA Program is to create an inclusive, dynamic, and nurturing environment where students can thrive beyond the traditional classroom. We aim to foster a love of learning, encourage creativity, and instill essential life skills that empower our students to become well-rounded, confident, and responsible individuals.
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STUDENT INFORMATION
Student First & Last Name *
Physical Address *
Gender *
Birthdate *
MM
/
DD
/
YYYY
Age *
Grade *
PARENT INFORMATION x2
Parent / Legal Guardian Name #1: *
Phone (Day) #1 *
Phone (Eve) #1 *
Phone (Cell) #1 *
Parent / Legal Guardian Name: *
Phone (Day) #2:  *
Phone (Eve) #2 *
Phone (Cell) #2 *
Email Address: *
SIGN OUT INFORMATION x2
Safety is a top priority at BSI; therefore, no child enrolled will be released from the program without a parent/guardian signature or that of one of the two individuals listed below if parent cannot be reached. (Note: The names that appear below must be someone 16 years or older.)
Name #1: *
Phone:  *
Name #2 *
Phone *
PHYSICIAN TO BE CALLED IN AN EMERGENCY
If you child is injured at school, we will clean the injury with soap and water, provide ice, a Band-Aid and TLC. “Accident Reports” are written out by the adult present and a copy will be emailed to the parent by the teacher. Any injury that requires more than the basics listed will necessitate a parent coming to the school to determine if professional medical care is needed.
Name *
Phone *
Address *
Medical Insurance Carrier:  *
ID#  *

Are there any medical, family circumstances or cultural requirements of which the leader should be aware of (Any known Allergies)? 

Current Medications:

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