Shores Baptist Academy

Child's First Name

Child's Last Name

Birth Date

Age

Gender

Male

Female

School

Grade (2019-2020)

Allergies

Parent/Guardian

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Work Phone

Emergency Contact #1

Emergency Phone #1

Emergency Contact #2

Emergency Phone #2

Lunch is provided for all participants in the program. Students may also bring their own snacks to eat during breaks or at times directed by the teacher. Transporation to and from the capsite will not be provided. Shores Baptist Worship Academy ad its employees are not responsible for any lost or stolen items.

MEDICAL RELEASE:
In the event of an emergency and I cannot be reached, I grant permission for emergency medical treatment to be given to any child. I agree to pay all medical bills not covered by my child's insurance policy listed below. I release Shores Baptist Academy and all its agents from responsibility for any bills resulting from injuries and incurred in the program. If applicable, I have attached information regarding allergies for other medical conditions about my child of which staff should be aware.

Insurance Company

Policy Number

PHOTO RELEASE

I give permission for my child to be photographed and for such photographs to be released only for publicity purposes.

I DO NOT give permission for my child to be photographed

FIELD TRIP CONSENT: IN THE EVENT THAT SHORES BAPTIST ACADEMY LEAVES THE CAMPUS OF THE PROGRAM.

I DO give permission for my child, to participate in off-site field trips arranged by Shores Baptist Academy.

I DO NOT give permission for my child to participate in off-site field trips arranged by Shores Baptist Academy. I understand that I will need to pick up my child early on these days.

Name of Parent/Guardian

Name of Child

Signature

Clear

QUESTIONS?
Contact Ms. Neciah Powell at (917) 865-7274 or at neciahp@gmail.com

Shores Baptist Worship Center

Shores Baptist Academy

Forms

Shores Baptist Worship Center

414 Silver Rd. Ocala, Florida