– APPLICATION – APPLICATION Name* First Last MALE FEMALE Grade*6TH7TH8THSchool* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent/Guardian* First Last Relationship to student* Phone*Email* Emergency Contact* First Last Relationship to student* Phone*MEDICAL RELEASE FORM* PARENTAL AGREEMENT I agree to indemnify and hold harmless those persons of Community Advance, Northwest Baptist Church, their employees, all personnel including consultants and volunteers participating in or associated in any manner with this event from claims of damages, liabilities, injury, expense or loss occurring out of its activities. In case of an accident or need of medical attention, I give my permission for The Summer Club and its staff and/or affiliates to take my child to a doctor and/or emergency facility. It is understood that all expenses incurred by any treatment will be the responsibility of the parent/guardian.DIGITAL SIGNATURE* First Last Date* MM slash DD slash YYYY Physician/Clinic's Name and Phone #* List any allergies or medication:* Insurance Company* Procedures & Guidelines* I agree to the privacy policy.-No vulgar or hateful language -No public displays of affection -No arguing or fighting -No bullying -Show respect to staff and volunteers If the above behavior guidelines are not followed, the student will be given a warning. If an issue has to be addressed again by the director, the parent/guardian will be called immediately to come pick up the student. Continuation in the program will be evaluated on an individual basis. There is zero tolerance for bringing drugs, alcohol, or weapons of any kind on the premise. If a student is found to be in possession, the police and parent/guardian will be notified and the student will not be allowed to return.Parental permission form* Parental agreement-I give permission for the above named student to travel with van drivers, staff and other volunteers -I give permission to use the above named student in photos, videos and social media for promotional purposes. -I agree the above named student will be picked up from The Summer Club by 5:00 PM and 3:00 PM on Fridays -I give my student permission to participate in life-skill presentations and biblical devotions.Student* I have read and agree to adhere to The Summer Club procedures and guidelines.Digital Signature* First Last Date* MM slash DD slash YYYY Parent/Guardian* I give the above named student permission to participate in all activities and programs at The Summer Club and agree to the terms of Community Advance.Digital Signature* First Last Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
