FUMCB After School Program

     Families, please complete one form per child. Thank you!

Last Name_____________________________________________________________________________________________

First Name_____________________________________________________________________________________________

Age ______________________ Child’s Grade (Fall 2011) _______________________________________________________

Date of Birth:  Month ____________Day _______Year ____________ School_______________________________________

Child’s Address__________________________________________________________________________________________

City / State ___________________________________________________________________ Zip ______________________

Parent’s/Guardian’s Name ___________________________   Cell Phone __________________________________________

                         Phone ____________________________ Email Address ________________________________________

Parent’s/Guardian’s Name ___________________________   Cell Phone __________________________________________

                         Phone ____________________________ Email Address _________________________________________

Persons authorized to pickup my child: 

1. Name _______________________ Phone _______________ Cell ______________ Relationship to Child: _____________

2. Name _______________________ Phone _______________ Cell ______________Relationship to Child: _____________

Persons to be contacted in case of emergency:

1. Name _______________________ Phone ________________ Cell _____________Relationship to Child: _____________

2. Name _______________________ Phone ________________ Cell _____________Relationship to Child: _____________

Does your child have any medical condition(s) that we should be aware of (allergies, medications, etc.)? If so, please explain._______________________________________________________________________________________________

_____________________________________________________________________________________________________

Doctor:_______________________ Address:____________________________________Phone:_______________________

·         I hereby give my permission for my child(ren) to participate in the First United Methodist Church of Bradenton After School Program.

·         I understand fees are due weekly by Tuesday of every week due directly to the After School Director or Business Manager.

·         I agree to be responsible for all cost of tuition. If tuition is not paid by Tuesday 6:00 pm there will be a late fee of $10. If the tuition is not paid by Thursday the child may not return to the program until all fees are paid.

·         I understand that the After School Program closes promptly at 6 pm. There will be a $10 charge if you arrive after 6. At 6:05 you will be charged an additional $1 per minute.

·         I hereby release the First United Methodist Church of Bradenton, and waive my right to make a claim against the First United Methodist Church of Bradenton, its staff and/or its volunteers, for any liability or damage arising from any injury sustained by my child while participating in any church or After School program or event.

·         I, hereby, grant permission to First United Methodist Church if Bradenton to use my child’s name and/or pictures for publicity as deemed appropriate.

·         In the event I cannot be reached in an EMERGENCY, I hereby give permission to staff of First United Methodist Church of Bradenton to take my child to a doctor or hospital for an emergency or surgical treatment and the physician selected by the staff of First United Methodist Church of Bradenton to hospitalize, secure proper treatment for, order injections, anesthesia, and/or surgery for my child as named above. I shall be responsible for any and all costs or expenses of providing such care and treatment for my child, and shall reimburse, indemnify, and hold harmless First United Methodist Church, its staff and volunteers from same.

Signed: __________________________________________________________ Date:   __________________________

*This must be notarized (one is available at no charge in the Church office).

Insurance Company: ________________________________________ Policy No.  ______________________________

Please return form to the First United Methodist Church of Bradenton, 603 11th Street West ● Bradenton, FL 34205

You may fax us at Fax 941-747-4407. Please feel free to call us with questions at 941-747-4406.