Teen Summer Nights Registration
Please fill out the following information to enroll in the Bethel School District Teen Summer Nights Program. This is a drop-in program and students can attend as often as they like. 
The program will run July 1-August 22 from 5:00-8:00PM.  No program July 3 & 4
Monday & Wednesday- Cedarcrest Middle School
Tuesday & Thursday- Bethel Middle School  
This program is for 6th-12th grade (24-25 school year) Bethel students only and students must show their student ASB upon entry or provide their student ID #. 
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STUDENT LAST NAME *
STUDENT FIRST NAME *
STUDENT LEGAL MIDDLE NAME *
STUDENT ID *
STUDENT EMAIL ADDRESS *
GENDER *
PHONE NUMBER *
WHERE DO YOU ATTEND SCHOOL? *
GRADE 2024/2025 SCHOOL YEAR *
MEDICAL & EMERGENCY CONTACT LAST NAME *
MEDICAL & EMERGENCY CONTACT FIRST NAME *
EMERGENCY CONTACT PHONE NUMBER XXX-XXX-XXXX *
RELATIONSHIP TO STUDENT? *
ALLERGIES/SPECIAL HEALTH CONCERNS?
I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for myself or my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian (if under 18) can be reached in the case of an emergency. I, on behalf of myself and/or my minor, agree to indemnify the Bethel School District and employees, members, and contractors harmless from all claims in case of an accident during activities related to this program, as long as normal safety procedures have been taken.  
I give permission to take photographs and / or video of my child. I grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the program goals.
The undersigned certifies, subject to the penalties of perjury, that the information above is true and correct to my knowledge.  Parent/guardian Signature *
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