REGISTRATION FORM
BEACON AFTER SCHOOL PROGRAM

FOR OFFICE USE ONLY

Immunizations Needed for Enrollmentl:   Date Registration Complete:

Date of eligibility, payment, and enrollment Cash  Check Number   Receipt Number
SCHEDULE: Middle School BEACON Schedule: Monday - Thursday from 3:00 - 5:30 PM
                         Elementary School BEACON Schedule: Monday - Friday from 3:00 - 5:30 PM|
ALL BEACON STUDENTS - GRADES K THRU 8 - MUST BE PICKED UP BY 5:30 PM

                    COST: Registration Fee is $10.00 by August 22, 2008. After that date the Registration Fee is $30.00

Name   List other names this child uses

Male      Female   Birthdate Grade 

FAMILY CONTACT INFORMATION

1st Contact: Name Address

Relationship to Child  e-mail Employer

Home Phone Cell Phone Work Phone  
 

2nd Contact: Name Address

Relationship to Child e-mail Employer

  Home Phone Cell Phone Work Phone


I have received and read the BEACON Parent Handbook.  I am committed to helping my child receive the best possible education and understand that I am the most important person in his/her educational development.  I support the goals of BEACON and will abide by the rules and policies that have been established and will encourage my child to do likewise.  I understand a late fee of $1.00 per minute will be assessed beginning at 5:30 PM and running until the time my child is picked up from the Director (or the police if they have taken custody of him/her).  (Please see Parent Handbook for further details.)    

           Parent Signature____________________________________________________________________ Date__________________

AUTHORIZATION FOR MEDICAL CARE OF MINOR

I, the undersigned parent, legal guardian, or person having legal custody of this child do hereby authorize Eufaula Public Schools to:

I.  Contact the following physician in case of emergency:  Physician's Name:

Physician's Phone Number Address

II.Administer prescription medication that has been prescribed for my child when I send it to school.  Over-the-counter medications such as Tylenol may also be given to the child IF I have provided it.  I understand that all medications must be in the original bottle with the instructions for the dosage on it.  Medication will only be given to the child whose name is on the bottle.  All medications must be submitted to the office. III. Notify alternate contact persons listed below if I cannot be notified quickly in case of an emergency.  They have the   authority to consent to emergency transportation, x-ray, medical, surgical or dental diagnosis or treatment as deemed necessary upon the advice of a physician, surgeon, or dentist licensed under the laws of the State of  Oklahoma. In the event that neither parent nor alternate persons can be reached, I authorize the Eufaula Public Schools to give these consents.
 Parent Signature_________________________________________________________________ Date_______________



In case of emergency if parent/guardian cannot be reached please notify (in order of preference):

Name Telephone Number

Name Telephone Number

 Name Telephone Number


HEALTH RECORDS  

Please check any health concerns that apply to your child.  
Asthma           Epilepsy           Diabetes           Allergic to bee stings or insect bites            Frequent nose bleeds  

Food allergies: (Please list)

Plant or mold allergies (Please list)  

Please list the medications your child takes on a regular basis:  


 FIELD TRIP PERMISSION FORM 
BEACON Students are often taken on field trips in the Eufaula area.  They may be bused to the Eufaula Memorial Library, another school site, a park, or a local business. 
           
Yes, this student may attend the local field trips    No, this student may NOT attend the local field trips


Parent Signature____________________________________________________________________________ Date__________________

RELEASE OF STUDENT

People picking up children must be at least eighteen (18) years of age. They will be required to produce a Photo ID unless they are personally knownto be of age to the school official releasing the student. 

CAUTION

A COURT ORDER PROHIBITS THE PERSON (OR PEOPLE) LISTED BELOW FROM PICKING UP MY CHILD:

**Official documentation must be provided to BEACON Coordinator
 


The following persons have my permission to pick up my child from the BEACON Program. 
Remember, do not list someone that is under eighteen (18) years of age

Name Relationship Telephone Number

Name Relationship Telephone Number

Name Relationship Telephone Number