(CHURCH USE ONLY)

Name:__________________ Grade:_________ Extended Care: _______ #:__________

Children’s Learning Center Camp

Entering Kindergarten through 3rd grade
June 28th – July 1st
9:00 am – 12:00 pm - camp & 12:00 pm – 5:00 pm - extended care

BROADWAY BAPTIST CHURCH – REGISTRATION FORM

(Please Complete One Registration Form Per Attendee)

Name: _______________________________________________________________________

Street Address: ___________________________________________ City: _____________

State: _________________________________________________ Zip Code: _____________

Home Telephone Number: (_____) ____________________________________________

Home Email Address: _______________________________ Age: ___________________

Date of Birth: ____________________ 09/10 school grade:_________________________

Days staying for extended care: _______ M ________T _________W _______Th

Name of person(s) that may pick up child: _____________________________________

In Case of Emergency, contact: _______________________________________________

Mother: _______________________ Father: _______________________________________

Guardian/Other: _____________________________________________________________

Allergies/medical conditions: _________________________________________________

Home Church: _______________________________________________________________

Cost:
9:00 am to 12:00 pm $90 for four days
12:00 pm – 5:00 pm $40 for four days.
$20.00 Registration Fee

Each child will need to bring their booster seat, and a sack lunch each day.