Before and After Care Enrollment

Please scroll down to complete the
form:

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*

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Name	Relation	Phone