A Purpose Driven AFTER SCHOOL PROGRAM
2701 Columbus Ave. Portsmouth, Va. 23704
Monday-Wednesday 4pm-7pm
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Name *
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Age *
Parent Name: *
Email *
Address *
Phone Name:   *
  Contact Information *
  School attends:    *
Does the student ride the bus? *
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What grade is the student currently attending?   *
Has the student attended any A Purpose Driven or Black Top Basketball events or camps? *
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Would the parent or parents wish to volunteer? *
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What neighborhood do you live?   *
Do you know your Civic League President? *
Required
Does your student have any allergies?    *
Does the student have any health concerns we should know about?   *

PHOTO RELEASE: 

I hereby grant the A Purpose Driven permission to take or have taken still and moving pictures of our/my son-daughter-ward and consent and authorize the A Purpose Driven to use or cause to be used such pictures for the primary purpose of promoting and aiding the A Purpose Driven and its work. I understand that the pictures will be used for program publicity. This photo release form will remain in force until revoked by me in the form of a written notice to A Purpose Driven. 


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