Little
Saints
Academy

GBTC
Childcare &
Afterschool Programs

Little
Saints
Academy

GBTC
Childcare &
Afterschool Programs

Greater Bethlehem Temple Church

Summer Academy Application

Please complete all required fields below. A $100 non-refundable registration fee must accompany this application. You may pay online via GBTC Giving or Brightwheel. Sibling discounts are available for multiple children in the same household.

Section 1

Student Information

Last Name *

First Name *

Date of Birth *

Age

Sex *

Male Female

Street Address *

City *

State *

ZIP Code *

School Name

Grade Level

School District

Section 2

Parent / Guardian Information

Father's Last Name

Father's First Name

Mother's Last Name

Mother's First Name

Home Address (if different from student)

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Email *

Employer

Section 3

Medical Information

Physician's Name

Physician's Phone

Physician's Address

Does your child have food allergies?

Yes No

If yes, list allergies

Is a special diet required?

Yes No

Does your child have any special needs?

Yes No

If yes, please describe

Section 4

Emergency Contacts

List persons (other than parents) to contact in case of emergency.

1st Contact Name *

Daytime Phone

Alternate Phone

2nd Contact Name

Daytime Phone

Alternate Phone

Section 5

Authorized Release

List persons (other than parent/legal guardian) to whom your child may be released at dismissal.

Name	Relationship

Person(s) your child CANNOT be released to

Section 6

Additional Information

Has your child participated in this program before?

Yes No

If yes, which year?

Are there any restrictions on your child's physical activities?

Yes No

If yes, please explain

Does your child have any special rulings or exceptionalities?

Yes No

If yes, please list

Section 7

Consent & Submission

Printed Name *

Date *