Youth Afterschool Enrollment Form

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Introduction

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Program Offering Exists - Hidden Field

Program Information

Program Name

Program Description

Beech Creek Ministries, Inc., Center for Imagination (CFI) provides academic enrichment opportunities to assist students meet state and local standards in core academic subjects with a focus on reading, math, and STEM.  We offer a broad array of enrichment activities such as robotics, art, music, spoken word, yoga, and gardening, in an effort to complement their regular academic programs.  CFI believes that children who have a positive self-image are more likely to perform better in school.  Therefore, our program is one that not only provides tools to support academic success, but also encourages self-discovery and an expanded worldview through our Courage to Be program.

Program Director Name

Program Director Email Address

Programs

Select Program

Student Information

Student First Name

Student Last Name

Name student would like to be called

Birthday

Student ID #

All ID numbers are at least 9 digits

Gender

MaleFemaleOther

How do you identify?

Is Student Home Schooled?

YesNo

School

Grade

Address Information

Address

City

State

Zip Code

Is this a new home address (moved in the last 6 months?)

YesNo

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

Primary Email

Phone

Lives with Student?

YesNo

Street Address

City

State

Zip

Would you like to add an additional Parent/Guardian?

YesNo

Parent/Guardian 2

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

Phone

Lives with Student?

YesNo

Street Address

City

State

Zip

Emergency Contact

Emergency First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Transportation Information

Student Address Street

Student Address City

Student Address State

Student Address Zip

Is the information above correct?

YesNo

Student Information Incorrect

Return to page 2 and correct Student Information

Transportation Permission

My student has permission to ride a Metropolitan Nashville Public Schools School Bus from school to my student’s regular bus stop to participate in extended school day activities. I understand that my student may be en-route on the school bus in excess of one (1) hour. I understand that transportation services may not be provided for my student if we reside in a parent responsibility zone. I further understand that services will not be provided on early release school days, snow days, or any other day school is not in session. My student and I understand that this service is a privilege, and further understand that bus service will be discontinued should the student misbehave or violate school system’s safety rules. My student and I have read the attached Bus Rider Rules and agree to abide by them.

Parent/Guardian Authorization

I give permission for student to be transported by the Metro Nashville Public Schools Transportation DepartmentI will decline the transportation services

Please provide the contacts of those who are authorized to pick up your child. Only those listed below will be allowed to pick up the student

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

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