Summer Depot 2016

---

______ # _______Amount ______Spreadsheet

Summer Depot 2016 Tuesdays & Thursdays 12 days June 7,9,14,16,28,30

_______Date Received _____$25 Reg. Fee Per Child

Total cost listed below ______________________Teacher

July 5,7,19,21,26,28

*$25 Registration Fee Per Child

1st Child: ____________________ Full Name: (First) (Middle) ____________________ Pertinent Allergies

___________________________ (Last) Name your child prefers

____ _____ M F

____/____/____ Birth date

__________________________ Special requests/needs for your child

Important medical or behavioral information to help your child be successful: _____________________ June 3,5,17,19,24,26 July 1,3,15,17,22,24 Circle Babies A, Toddlers B, Toddlers C (9:00-1:00) (Babies: 8 weeks to 1 year, Toddlers B: 1 year to 24 months, Toddlers C: 2 years old) * $210 for the summer _____

Circle Pre-K 2, Pre-K 3, Pre-K 4, K-1-2(9:00-12:00) (2 by Sept 1, 2015, exiting/leaving learning grade)

* $180 for the summer _____

Early Bird (8:00-9:00) _____ +$72

Early Bird (8:00-9:00) _____ +$72 Lunch Bunch (12:00-1:00) ______+$72

2nd Child: ________________________ _____________________________ ____/____/____ Full Name: (First) (Middle) (Last) Name your child prefers Birth date ____________________ Pertinent Allergies

____ _____ M F

__________________________ Special requests/needs for your child

Important medical or behavioral information to help your child be successful: ______________________ Circle Babies A, Toddlers B, Toddlers C (9:00-1:00) (Babies: 8 weeks to 1 year, Toddlers B: 1 year to 24 months, Toddlers C: 2 years old) * $210

Circle Pre-K 2, Pre-K 3, Pre-K 4, K-1-2 (9:00-12:00)

for the summer _____

Early Bird (8:00-9:00) _____ +72

(2 by Sept 1, 2015, exiting/leaving learning grade)

* $180 for the summer _____ Early Bird (8:00-9:00) _____ +$72 Lunch Bunch (12:00-1:00) ______+$72

Mom’s First & Last Name: ___________________________Employer: ________________ Mom’s Cell #____________ Dad’s First & Last Name:_____________________________Employer:_________________ Dad’s Cell #____________ Address: _______________________________ City ___________________ Zip __________

Office:

E-Mail Address: _______________________________________________________________ Emergency Contacts: Name_________________________________________ #______________________________ Name________________________________________ #____________________

Medical Release

In enrolling my child (children) in the Summer Depot Ministry at Temple Baptist Church of Hattiesburg, MS, I understand that Temple

Baptist Church assumes no responsibility for sickness or injury which may occur while my child (children) is (are) in attendance at the Summer Depot. As a condition of enrollment of my child (children) in Summer Depot, I hereby relieve and release TBC and its employees from any and all liability for injury or sickness which may occur for any cause while my (our) child (children) is (are) in this program. In order to meet all legal requirements, I hereby authorize a representative of TBC to give consent for any and all necessary medical care for my child (ren) while in TBC’s custody.

Parent’s signature: ____________________________________ Date: ______________