Bentworth Released Time Registration Form
For multiple students, please submit one form per student.
Classes will meet on Tuesdays beginning Sept. 24th and running through the end of May. Third and Fourth grade will meet from 12:15-1:15pm and 5th through 7th will meet from 1:20-2:20pm. Transportation is provided.
School *
Please confirm your school by selecting it below:
About you (parent or guardian)
Parent/Guardian Name *
Your answer
Relationship *
How are you related to the student you are registering?
Your answer
Email *
Your Email will not be given to anyone else, and is used by us for infrequent communication and announcements.
Your answer
Contact Information
Your mailing address will not be given to anyone else, and is used by us for infrequent promotional mailings.
Mailing Address Line 1 *
Your answer
Mailing Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Phone Number *
As with Email and Mailing Address, we do not give out phone numbers. We will only use this number if we need to contact you when mailing or Email is not a viable option. This will also be used as a number where we can reach you if there is an emergency. If this is not your number, please also provide the name of the person to whom the number belongs.
Your answer
About your student
Student Name *
Your answer
Gender *
Current Grade (3rd-7th) *
Your answer
Birthdate *
Does your student attend church regularly? *
Church currently attending
If your student attends a church regularly, please indicate that below. If they do not, or you care not to answer, just leave blank.
Your answer
Allergies or Medical Conditions
Please tell us anything we should know regarding your student's health
Your answer
Mailbox Club
Our Bible Correspondence Lessons provide students with an opportunity to dig deeper into God's Word at their own pace. Completed lessons are graded and returned with the next lesson. Students earn $25 towards summer camp for every 3-4 lessons they complete!
Do you wish to enroll your student in Mailbox Club? *
Please note that by submitting this form, participation in Released Time by your student is expected until you give us notification otherwise. Please also note that if you need to pick your child up from Released Time classes, you must first contact the SCHOOL, not the Released Time provider to make arrangements.
Permission to participate *
By typing my full name below, I confirm that I am the legal parent or guardian of the student named above, and give the student permission to be released from school on the dates and times indicated on this form to attend Bible classes. I also give Children's Bible Ministries of Southwest PA, the Released Time provider, permission to use video and/or photos of my child taken in class for promotional material. I also understand that my student's participation in Released Time Bible classes is expected until I give notification otherwise.
Your answer
Comments or questions?
Your answer
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