Good News Clubs – Smith

Registration for Captain John Smith Good News Club

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Good News Clubs - Smith

Time: 2:45pm until 4:00pm
Date: Thursdays starting October 3rd, 2024
Place: Captain John Smith Elementary School - Activity Room
Who can attend? All boys and girls in grades 3rd-5th, regardless of religious
background. Parents are also welcome to attend with their child anytime.
Sponsored by: Bethel Baptist Church & CEF of VA Peninsula
Contact for Information: Korey Kelley, cefpeninsula@gmail.com

Child Name *

Birthday - (e.g.; 10/23/2018) *

Age *

Gender *

Male

Female

Grade Level (K, 1, 2, 3, 4, 5) *

Homeroom Teacher *

Child Allergies *

Yes

No

If yes, please list allergies (peanuts, chocolate, etc.)

Is parent in military? *

Yes

No

Does your child attend church?

Yes

No

Name of church attending

Parent/Guardian Name #1 *

Parent/Guardian Phone #1 *

Parent/Guardian Email #1 *

Parent/Guardian Name #2 *

Parent/Guardian Phone #2 *

Parent/Guardian Email #2 *

Address *

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Select how your child will get home on club day. *

My child will be picked up

My child will transition to the school’s extended day/after-school program.

These people (include phone numbers) are allowed to pick up my child if I’m not able to:

Name *

Phone Number *

Name

Phone Number

I give my permission for my above-named child to attend the Good News Club during the 2022-23 school months. *

Yes

I understand it is my responsibility to pick up my child immediately when the club ends. *

Yes

I will send a note to the school requesting my child stay after school to attend the Good News Club. *

Yes

I give permission for photographs/videos of my child to be used in club and ministry promotions.

Yes

Parent/Guardian Signature: Enter your signature in the box using your finger on the touch-pad/track-pad or with your mouse's cursor in the box. *

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Date

Reference Number

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THESE MATERIALS ARE NEITHER SPONSORED NOR ENDORSED BY THE HAMPTON SCHOOL DIVISION NOR THIS SCHOOL.