Berea Lutheran Church 7538 Emerson Ave S Richfield MN 55423

612-861-7121

beforeandaftercare@berealutheran.org

Student Information

#1 Child’s Name

Last: Click or tap here to enter text.

First: Click or tap here to enter text.

Middle Initial: Click or tap here to enter text.

Age: Click or tap here to enter text.

Birthday: Click or tap here to enter text.

Grade 2017-18: Click or tap here to enter text.

Sex: Male ☐ Female ☐

#2 Child’s Name

Last: Click or tap here to enter text.

First: Click or tap here to enter text.

Middle Initial: Click or tap here to enter text.

Age: Click or tap here to enter text.

Birthday: Click or tap here to enter text.

Grade 2017-18: Click or tap here to enter text.

Sex: Male ☐ Female ☐

Parent/Guardian Information

Father/#1 Guardian’s Name: Click or tap here to enter text.

Address: Click or tap here to enter text.

Place of Employment: Click or tap here to enter text.

City: Click or tap here to enter text.

Business Telephone#: Click or tap here to enter text.

Cell Phone#: Click or tap here to enter text.

Email: Click or tap here to enter text.

Driver’s License#: Click or tap here to enter text.

Mother/#2 Guardian’s Name: Click or tap here to enter text.

Address: Click or tap here to enter text.

☐ same as Father/ #1 Guardian

Place of Employment: Click or tap here to enter text.

City: Click or tap here to enter text.

Business Telephone#: Click or tap here to enter text.

Cell Phone#: Click or tap here to enter text.

Email: Click or tap here to enter text.

Driver’s License#: Click or tap here to enter text.

Contact First: Father ☐ Mother ☐

2 Emergency Contacts (Other than Father and Mother; must be two different addresses)

#1 Name: Click or tap here to enter text.

Phone #: Click or tap here to enter text.

Relationship: Click or tap here to enter text.

Address: Click or tap here to enter text.

#2 Name: Click or tap here to enter text.

Phone #: Click or tap here to enter text.

Relationship: Click or tap here to enter text.

Address: Click or tap here to enter text.

Health Information

Physician: Click or tap here to enter text.

Phone#: Click or tap here to enter text.

Address: Click or tap here to enter text.

Health Insurance Company: Click or tap here to enter text.

Policy Number: Click or tap here to enter text.

Name of Insured: Click or tap here to enter text.

Medications: Click or tap here to enter text.

Allergies: Click or tap here to enter text.

Religious Background (optional)

Are you a member of any Church or place of worship? ☐ Yes ☐ No

If Yes, name and address. Click or tap here to enter text.

Other Information

Languages spoken at home Click or tap here to enter text.

Any other important information about your family we should know? Click or tap here to enter text.

Registration Fee

There is a Family registration fee of $15 per family due before the registration is complete. Please make Checks out to: Berea Lutheran Church.

Attendance Options

Option #1:☐ Check box

Please mark the days your child will be attending before and after care programing. Minimum 6 sessions for entire week.

Child #1

Before/AM Session

☐M ☐T ☐W ☐Th ☐F

Total # sessions Click or tap here to enter text. X $10=Click or tap here to enter text.

After/PM Session

☐M ☐T ☐W ☐Th ☐F

Total # sessions Click or tap here to enter text. X $10=Click or tap here to enter text.

Child #2

Before/AM Session

☐M ☐T ☐W ☐Th ☐F

Total # sessions Click or tap here to enter text. X $10=Click or tap here to enter text.

After/PM Session

☐M ☐T ☐W ☐Th ☐F

Total # sessions Click or tap here to enter text. X $10=Click or tap here to enter text.

Option #2:☐ Check box

Full week of Before/AM or After/PM sessions mark which one.

Child #1

Before/AM☐ After/PM ☐

5 sessions X $10=$50 per week

Child #2

Before/AM☐ After/PM ☐

5 sessions X $10=$50 per week

Option #3:☐ Check box

4 or less sessions a week or drop-in.

Fill out monthly calendar, pick your days for the month ahead, and send in with registration. For drop-in please call or email 24 hours before session to get confirmation from program.

$13 per session.

Agreement

The completion of this registration form and the electronic signature of the parents/guardians constitutes an agreement that the fees of any child registered will be paid, in a timely fashion, by the parent or guardian signing.

Electronic Signature of Parent/GuardianClick or tap here to enter text.

Electronic Signature of Parent/GuardianClick or tap here to enter text.