B.L.A.S.T.

Believing, Loving, And Serving Together

Wednesday Evenings

September 13, 2023-May 8, 2024

Ages Preschool through High School

Blast Registration

2023-2024 School Year

Child's First Name

Date of Birth

Child's Last Name

Grade

Child's Cell Phone # if applicable

Parent/Guardian Name

Best Contact Phone Number

Street Address

City, State, Zip Code

Alternative Emergency Contact

Phone Number

Physician's Name

Insurance Company

Policy Number

Does your child have any allergies?

Yes

If so, what?

Any medical conditions we should know about?

Medical Treatment

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attend-ing physician and/or paramedics for my child and waive my right to Informed Consent of Treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency

Field Trips

I give permission for my child to go on field trips. I release Antioch Church and individ-uals from liability in case of accident during activities related to Antioch Church, as lon-g as normal safety procedures have been taken.

Photo Release

I give my permission for my child to be photographed and/or videotaped by Antioch Church during activities and/or events. I understand that photographs and videotapes may be released to the media and the public to promote Antioch Church programs or events.

I DO NOT want my child to be photographed and/or videotaped.

List any court appointd restrictions:

We look forward to seeing your child in BLAST!

Schedule

3:30-4:00PM- Arrival & Snack

4:00-5:15PM- Recess/Homework Time

5:15-5:45PM- Dinner

5:45-6:15PM- Bible Study

6:15-7:15PM- Class Time

7:15-7:30PM- Pick Up

*Schedules vary depending on age group.

Transportation is provided from W.W. Robinson, Peter Muhlenberg, Central High School, and The Growing Tree.