Before and After Care Enrollment - Lighthouse Baptist Academy

Before Care: 6:30 a.m. - 7:30 a.m.
After Care: 3:15 p.m. - 6:00 p.m.

Enrollment Type*

Will your child be attending monthly or daily?*

Is your child a student at LBA?*

Yes
No

Due to COVID restrictions, our Before / After Care program is limited to students currently enrolled in our school.

Grade*

Child's Information

Child's Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Gender*

Birthdate*

Does the child have any physical limitations or disabilities?*

Limitations / Disabilities

Parent's Information

Home Phone*

Cell Phone*

Email*

Father's Name*

First Last

Father's Employer*

Father's Work Phone

Mother's Name*

First Last

Mother's Employer*

Mother's Work Phone

With whom does the child live?*

Authorized Pick-up List*

Please list any adults other than the father or mother who are approved to pick up your child.

Name	Relation	Phone

Consent and Sign

By signing this form, I as the parent or legal guardian, give permission for my child to travel on the school's transportation to and from the Before and After Care school program. In doing so, I absolve Lighthouse Baptist Church and Academy, its insurers, agents, employees, board, representatives, and assigns from any and all causes of actions, claims, demands, or expenses in any way connected with or arising out of said transportation.

Signature of Parent / Guardian*

Today's Date*

Before Care: 6:30 a.m. - 7:30 a.m. After Care: 3:15 p.m. - 6:00 p.m.

Child's Information

Parent's Information

Consent and Sign

Before Care: 6:30 a.m. - 7:30 a.m.
After Care: 3:15 p.m. - 6:00 p.m.