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DETROIT, MICHIGAN
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BETHEL EAST
KIDS AND TEENS PROGRAM
ENROLLMENT
Participant First Name
Participant's Birthday
*
required
Participant Last Name
Age:
Parent/Guardian's Name:
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Phone
Email
As the parent/guardian of this participant, I give permission for him/her to attend the following selected Bethel East Clubs / Progams / Activities:
*
Required
Kids Club (12 & Under, Pre-K - 8th) Friday's 6-8:30pm
Teen Club (13-19) Friday's 6-8:30pm
I am interested in the following additional progams/minstries for my child:
Piano Lessons
Drums Lessons
Vocal Lessons
Tutoring
Praise Dance Ministry
Youth Choir
One-on-One Counseling with qualified counselors
Sports
Summer Employment Program for Teens
We live in a 10-mile radius of the church and need transportation
I give permission for routine medical treatment to be administered to my child. In case of an emergency and I cannot be reached, I give the staff permission to secure the necessary emergency medical treatment for my child. I hereby expressly waiver any and all liabilities, damages, actions, or causes of action on the part of Bethel Baptist Church, East for any such injury unless is a direct result of the gross negligence or intentional acts of the staff. In addition, I understand and agree that Bethel Baptist Church, East is authorized to make audio and/or video recordings of the program activities, and I give permission for CDC to record this child’s picture and voice on photographs, films, and tapes, without payment, and to incorporate these recordings into public relations and advertising materials and to use in any manner of media whatsoever.
In case of an emergency and you are not available, please list below someone we can contact:
Please list any special needs, if any, regarding your child we should be aware of (Allergies, Medications, Special Behavior Instructions):
Please write your first and last name which will serve as an E-signature for this:
Enroll
God Bless You!
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