2019-2020 Good News Club Student Registration Form Grace Community Church / Blandford

Who can attend? All boys and girls, grades 5th, regardless of religious background. Parents are also welcome to attend with child, however interaction with other children is not allowed without a background check on file with CEF. Please note that registrations need to be completed by Wednesday in order to attend club the next week.

Acknowledgements

My child (named below) is allowed to attend the Good News Club at BLANDFORD ELEM, every MONDAY after school

Yes No

I understand it is my responsibility to pick up my child at 4:00PM and failure to do so will jeopardize my child’s continued participation

Yes No

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You are agreeing that you have read and understand the statements listed above.

Your Name

Child's Information

Child's Legal Name

Nickname

Birthdate

Homeroom Teacher

Grade

Kindergarten !st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade

Gender

Female Male

Address

County

Bryan County Bulloch County Chatham County Effingham County Evans County Screven County

IF YOU ANSWER NO TO ANY OF THE QUESTIONS BELOW PLEASE PUT N/A IN 'EXPLAIN' SECTION. THANK YOU.

Are there any security / custody issues with this child?

Yes No

Security - Please explain

Does your child have any special needs we should be aware of (ADD, Autism, Dyslexia, etc.)?

Yes No

Any special needs or anything we should know about your child - Please explain:

Does your child have any allergies (peanuts, chocolate, etc.)?

Yes No

Allergies - Please explain:

Indicate how your child will get home on club day

My child will be picked up after Good News Club My child will walk home after Good News Club My child is registered for and will attend extended day/after-school program

Contact Information

Please enter the BEST mobile number to reach someone.

Phone

Please enter the BEST email address for correspondence with your child's Good News Club.

This address will receive a confirmation email

Dad's Name

Dad's Phone

Mom's Name

Mom's Phone

Emergency Contact #1 Name

Emergency Contact #1 Phone

Emergency Contact #2 Name

Emergency Contact #2 Phone

Permission for Pick Up

Below is a list of names allowed to pick my child up from Good News Club **(Please include your name as a pick up person)**

Pickup Person #1 Name

Pickup Person #1 Phone

Pickup Person #2 Name

Pickup Person #2 Phone

Pickup Person #3 Name

Pickup person #3 Phone

Additional Information

Is either parent in the military?

Yes No

Church your family attends, if any

OPTIONAL Photography and Video Release

Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos. I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

I approve the above Photography and Video Release

Yes No

Child's Name

If Yes, name of parent giving permission (if No, enter N/A)

Description

MONDAY 2:30PM UNTIL 4:00PM

Thank you for registering your child in the Good News Club at BLANDFORD ELEMENTARY SCHOOL!

Please complete this form in it's entirety and submit. Complete one form per child. You will receive a confirmation, as well as a confirmation email with all the details about this Good News Club including start date and contact information.

Sponsored by: Child Evangelism Fellowship Southeast Georgia Chapter.
Hosted and Conducted by: Grace Community Church
Coordinator: Pam Corbitt
Time: 2:30pm until 4:00pm
Date: Every Monday starting September 30th - only on full days of school
Room: Media Center
Who can attend? All boys and girls grades 5th regardless of religious background. Parents are also welcome to attend with child.

2019-2020 Good News Club Student Registration Form Grace Community Church / Blandford

Description

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