Homeschool-Life.com - Homeschool Group and Co-op …
Broward Education Homeschool Classes _____ /_____ Registration & ReleasePlease Submit One Form for Each Student ___________________________________ ______________________________ _____________ _____________PRINT STUDENT’S LAST NAME FIRST NAME GRADE 2016-2017 DATE OF BIRTH _________________________________________________________ ________________________________________________________PARENT’S NAME (MOTHER) (FATHER)_________________________________________________________________________________________________________________________ADDRESS_________________________________________________________ ____________________________/______________________________HOME PHONE CELL PHONE (MOTHER) (FATHER)_________________________________________________________ ___________________________________________________________PARENT’S E-MAIL ADDRESS STUDENT’S E-MAIL ADDRESS_________________________________________________________ ___________________________________________________________EMERGENCY CONTACT/RELATIONSHIP PHONE NUMBER(S)Does this student have any medical conditions or allergies? YES / NO _________________________________________________________________________________EXPLAINMy parents and I have read the BEHC Handbook and Code of Conduct. We understand and agree to abide by such code. In addition, at least one parent agrees to attend the fall MANDATORY Parent meeting. It is a requirement that in order to participate in BEHC, you must also be a member of the Broward County Parent Support Group (PSG).________________________________ _________________________________________PARENT SIGNATURE STUDENT SIGNATURERELEASEAll classes and activities for BEHC are planned and organized by individual volunteers. Each participant must assume the risk of physical injury that could result from any of these activities and classes. Consequently, I release Victory Life Church, its employees and volunteers, and all BEHC directors, volunteers and instructors from all liability for any injury to myself, my family or dependents as a result of participating in BEHC activities or classes._________________________________________________________ ______________________________________________________________PRINT PARENT’S NAME PARENT’S SIGNATUREState of Florida, County of _______________________________Subscribed to and sworn before me this _________day of _____________________, 2016 by _________________________________________who is personally known to me or has produced _______________________as identification. Notary Public __________________________________ My Commission Expires ___________-6032511557000 NONREFUNDABLE Registration Fee $30.00/student $ 30.00___ NONREFUNDABLE PSG Membership Fee $35.00 $ 35.00___ Donations for BEHC Financial Aid / Brenda Dickinson, HEF $__________ TOTAL $__________ Please make all checks payable to Broward Homeschool PSG ................
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