Application blank for Enrollment in the Salt & Light Wednesday program. (Starting September 12. Please print and fill out.)                         

 Salt and Light Registration 2012-2013

Name __________________________ DOB _________ Grade _________

Name __________________________ DOB _________ Grade _________

Name __________________________ DOB _________ Grade _________

Name __________________________ DOB _________ Grade _________

Legal Guardians: _______________________________________________

_________________/____________________/_______________________

              (Home #)                                           (Cell #1)                                                (Cell #2)

Mailing & Street Address: ______________________________Zip: _______

Contact e-mail: __________________________________________________

Emergency Contact: _________________________phone/cell: ___________

Other people my children are allowed to go home with: _________________________

We need help with transportation ____ School(s): _______________________________

Parent Participation – Active participation by at least one adult member of each student’s family is requested. Since Salt and Light is primarily run by volunteers, your help is essential to keep the many activities going. The morale boosting effect of the families’ presence is equally important. Check the areas where you would be interested in helping:

___ Recreation Helper           ___ Kitchen Crew (1x mo.)   ___ Childcare Assistant

___ Teacher/Asst.                  ___ Help prepare Snacks                  ___ Table Parent (weekly)

___ Decorator/Set Tables ___ Launder Tablecloths            ____Articles/Advertising                 ___ Driver                        ___ Other

Medical release and liability waiver:

I, the undersigned, am the Parent/legal guardian of the above named child(ren) and give permission for him/her/them to attend Salt and Light and associated activities. I understand that there may be inherent risks involved in any ministry or athletic event, and release the Church, its staff, agents, or volunteers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement. In the event the child(ren) require the attention of a doctor, I consent to any reasonable medical treatment deemed necessary by a licensed physician. In the event he/she is injured and requires the attention of a doctor, I give consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from giving such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by my health insurance provider.

Signature of Legal Guardian: _____________________________Date:__________________________

Photo Release:  ___Yes, FPC may use  No, FPC may not use ___ pictures of my child/ren for church publication.

 The guidelines of Salt and Light are:

“We are all Children of God. At Salt & Light, we treat others as we would like to be treated.”

To help everyone be clear what this looks like we ask each family to read and affirm the following:

1.      I will respect fellow students and adults.

2.      I will participate in all activities to the best of my ability.

3.      I will act in a safe and responsible manner.

4.      I will only leave the program with my guardian, & will be sure to let my teacher/tableparent know.

5.      I will have fun!

Student Signature(s): __________________________________________________________________

Legal Guardian Signature(s): ____________________________________________________________

Attention Parents: By initialing on this line my child(ren) have permission to walk or drive home after Salt and Light without an adult ____________.

Our ministry is open to everyone, regardless of donation given.  Our suggested donation is $35/semester or $70/family/semester.  This helps us cover curriculum and food costs.

For Office Use Only:

Amount Paid: ______________________  Received Date: ________________  Initials: ____________

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Send comments, suggestions, and requests to Alex. F. Burr or send e-mail to aburr @ aol.com.
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Last update 2012-07-26 21:22:41