Summer Enrichment Program Registration Form

Student Name*

First

Last

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Date of Birth*

Age*

* Sex

* Race/Ethnicity

Note: *Gender, Race/Ethnicity identification is for statistical purposes only.

Current School*

Grade Completed 2024-2025 school-year:*

List some of the subjects or activities that interest you.

Allergies/Medical/Special Needs Information:*

PARENT INFO:

Parent 1 Info

Parent 1 or Legal Guardian 1 Name:*

Parent / Guardian 1 Place of Employment:*

Parent / Guardian 1 Work Phone

Parent / Guardian 1 Home Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Parent 1 or Legal Guardian 1 Home Phone *

Parent 1 or Legal Guardian 1 Cell Phone*

Parent 1 or Legal Guardian 1 Email*

Parent 2 Info

Parent 2 or Legal Guardian 2 Name:

Parent 2 or Legal Guardian 2 Place of Employment:

Parent 2 or Legal Guardian 2 Work Phone

Parent 2 or Legal Guardian 2 Home Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Parent 2 or Legal Guardian 2 Home Phone

Parent 2 or Legal Guardian 2 Cell Phone

Parent 2 or Legal Guardian 2 Email

Provide the name ('s) of person ('s), other than the parent, allowed to pick up the student.

Name

Relationship to student

Phone Number

CHURCH INFORMATION (If applicable):

Name of Church Attending:

Pastor

Church Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Tee-Shirt Size*

ACTIVITY/FIELD TRIP PERMISSION FORM

Child Name*

First

Last

I give my child permission to attend all FIELD TRIPS/ACTIVITIES/ SPORTS planned by Bethlehem Baptist Union Summer Enrichment Program. Bethlehem Baptist Union, Inc. will take every reasonable precaution to keep your child safe; however; Bethlehem Baptist Union, Inc. does not assume legal responsibility for circumstances beyond its control.
Signature of Parent/Guardian*

Activity/Field Trip Permission Parent Signature Date*

Parental Consent for Release of Student Photograph and Media Information

I hereby give permission for Bethlehem Baptist Union, Inc. to use my child’s photograph, video image, writing, voice recording, name, grade level, school name, description of participation and statistics in officially recognized activities and sports, diplomas and awards received, in annual yearbooks, newspapers, graduation programs, playbills, school productions, web sites, etc and/or similar school publications or in school approved news media interviews, articles and photographs. I understand that, without my signature, my child’s name and photograph cannot and will not be included in any publications or presentations, including a school yearbook.
Signature of Parent/Guardian(1)*

Parental Consent for Release of Student Photograph and Media Information Signature Date(1)*

Program Fee: $0.00 (The Program is Free to All Students)

Please Note:

1.The SummerEnrichment Program will apply only to students who will be in the 6^th–9^th grade in the 2025-2026 school year.

2.Theprogram will be held from July 7- 18, 2025 at Bethlehem Baptist Union located at 5556 Carolina Highway, Denmark, SC,from 9:00 AM – 3:00 PM.

3.Students and Parentsshould complete the Registration Form and email it to [email protected] or mail to the addressbelow by June 15, 2025:

Bethlehem Baptist Union

P. O. Box 277

Denmark, SC 29042

4.Registration can alsobe completed online at Bethlehem Baptist Union website at www.bethlehemunion.org and should besubmitted by June 15, 2025.

5.If you have any questions about the program or theregistration process, please contact Lenon Brooker, Program Director by emailat [email protected] or by phone at (803)571-1296.