Laguna Presbyterian Church

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Homework Club 325
Mondays, Winter/Spring 2024

Starting January 22
3 - 5pm

WHAT:	Club 325 Afterschool Homework Club, Kindergarten - 5th graders! Educational tutors will help with all subjects!
WHEN:	Mondays from 3 – 5 pm, (doors open at 2:45), snack provided 3-4 pm Faith and Fun; 4 – 5 pm Homework and Tutoring
WHERE:	Laguna Presbyterian Church, Youth Center Parents can drop off and pick up students in the Youth Center
HOW:	Fill out the permission slip below and pay online.
COST:	$15/session 1st child. Additional children $10/session. Register for 4, 6 or 8 sessions at a time. Sessions do not have to be used consecutively. Drop-ins are welcome with payment and signed permission slip.
CALL:	Gail Onodera at 494-7555
EMAIL:	gonodera@lagunapreschurch.org

Registration

Qty

Description

Amount

Total

First Child

$15.00

---

4, 6, or 8 Sessions
Cost per session

Second Child

$10.00

---

4, 6, or 8 Sessions
Cost per session

Third Child

$10.00

---

4, 6, or 8 Sessions
Cost per session

Total: $0.00

Child’s #1 Name:

Age and Date of Birth:

Current Grade:

School:

Gender:

Known allergies/medical conditions:

Child’s #2 Name:

Age and Date of Birth:

Current Grade:

School:

Gender:

Known allergies/medical conditions:

Child’s #3 Name:

Age and Date of Birth:

Current Grade:

School:

Gender:

Known allergies/medical conditions:

Parent/Guardian Information

Parent/Guardian Name(s): *

Street Address:

Home Phone: *

Cell Phone: *

Medical Consent and General Release

Medical Consent and General Release for CLUB 325 for Winter/Spring 2024:
I/We do hereby release the staff and officers from liability of accident, illness or injury during his/her participation in the Club 325 activities of Laguna Presbyterian Church. I/We authorize the persons presenting this form to call a physician and to consent to any transportation, x-ray examination, anesthetic, medical or surgical diagnoses or treatment and hospital care which is deemed advisable for my/our minor children in case of emergency. It is understood that a conscientious effort must be made to notify me/us before such action is taken. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

Medical & General Consent Agreement: *

I agree with the above statement.

Name:

Relationship to child:

Emergency phone contact #1:

Emergency phone contact #2:

Physician:

Emergency Phone:

Insurance:

Allergies:

The following adults are allowed to pick up my child(ren)

Designee #1:

Cell Number:

Date(s) To Pick Up:

Designee #2:

Cell Number:

Date(s) To Pick Up:

Permission to photograph:
I give my permission for Laguna Presbyterian Church to take photo / media images of my child for publication in church created media.

I give my permission for Laguna Presbyterian Church to submit photo / media and my child's information to the local newspapers for potential press releases, articles and television, knowing that my child's name may be printed in the publication or spoken on television.

Photo/Video Release: *

I have read, understand and agree to Laguna Presbyterian Church’s policy above.

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *