REGISTRATION | Bright Stars

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We're Open | AFTER SCHOOL
SUMMER CAMP STARTING SOON

Beyond the School Day

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REGISTER YOUR CHILD TODAY!

Step #1
Complete the Registration Form below.
Registration is not complete until your $25 Registration Fee is received.

Step #2
Separately, submit your $25 Registration Fee on our Online Payment Form

Registration Form

STUDENT INFORMATION

Select what type of registration: *

2024/2025 Summer Camp

2025/2026 Academic Year Registration

2025/2026 Winter Break

2025/2026 Spring Break

Enrollment Status *

First Time Attending

Returning Scholar

Student ID - Please Include if Available

School Attending

Grade Currently In

Scholar First Name

Scholar Last Name

Boy or Girl

Age

Date of Birth

Scholar's Address

Zip Code

Any allergies (food, insect bites, etc.)? Please list them and any special medications required.

PARENT INFORMATION

Your relationship to Scholar/Student *

Mother

Grandmother

Aunt

Legal Guardan

Other

N/A

PARENT / LEGAL GUARDIAN

Parent Email

Home Phone

Cell Phone

Address if different than Scholar's

Zip Code

Your relationship to Scholar/Student *

Father

Grandfather

Uncle

Legal Guardan

Other

N/A

PARENT / LEGAL GUARDIAN

Parent Email

Home Phone

Cell Phone

Address if different than Scholar's

Zip Code

Safety is priority for the “Bright Stars - Beyond the School Day;” therefore, no child enrolled in “Bright Stars” will be released from the program without a parent/guardian signature or that of one of the three individuals below. (Note: The names below must be of someone 16 years or older.)

STUDENT SIGN-OUT INFORMATION

Pickup Person No. 1

Relationship - No. 1

Contact Number - No. 1

Pickup Person No. 2

Relationship - No. 2

Contact Number - No. 2

Pickup Person No. 3

Relationship - No. 3

Contact Number - No. 3

Thanks for submitting!

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OTHER REQUIRED FORMS

Please complete for each child enrolled at Bright Stars, the
Photography & Video Consent & Release Form and Medical Emergency Form.
These forms are required before your child's start date.

The Medication Consent Form only needs to be completed if your child(ren) requires medication during After School or Summer Camp hours.

Photography and Video Consent & Release Form

Parent/Guardian

Parent/Guardian

Email

Student First and Last Name

Date of Birth

As parent or guardian, I hereby consent to the use of photographs/videotape taken during the school year for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet, or other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.

Parent/Guardian Initials

Thanks for submitting!

Medical Emergency & Health Declaration Form

Please fill out the following form
in order to participate in Bright Stars.

Parent / Guardian

Parent / Guardian

Cell Phone

Email

Student

Date of Birth

Name of Child's Doctor

Doctor's Phone

Doctor's Address

Doctor's Address - Second Line

Name of Child's Dentist

Dentist Phone

Dentist Address

Dentist Address - Send Line

Insurance Policy/Number

Additional Insurance Policy/Number

Hospital Preference

Hospital Phone

Hospital Address

Hospital Address - Second Line

Health Hitory: Check all that apply. Describe if necessaery.

Visual Impairments

Hearing Impairments

Ear Infections

Flu Vaccine Shot

COVID-19 Vaccine Shot

Asthma

Measels

Mumps

Diabetes

Heart Disease/Defect

Convulsions/Seizures

Chicken Pox

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Allegies - Check all tht apply.

Hay Fever

Plant Poisoning

Insect Stings/Bites

Penicillin

Animals

Seasonal/Outdoor

Foods: Describe below

Other/Special Instructions:

DESCRIPTION

I declare that the info I’ve provided is accurate & complete

Parent/Guardian Initials

Thanks for submitting!

You may also DOWNLOAD these forms and complete them in hard copy and submit to the Director before the start date.

Please complete for each child enrolled at Bright Stars, the
Photography & Video Consent & Release Form and Medical Emergency Form.
These forms are required before your child's start date.

The Medication Consent Form only needs to be completed if your child(ren) requires medication during After School or Summer Camp hours.

© 2017 by UMBA Bright Stars, Inc. After School Program

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Call Us: 704-579-7642 / prlborders@aol.com / Greater Bethel A.M.E. Church | 5232 The Plaza | Charlotte, NC 28215

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