Cccsb T.g.i.f. Power Club Application Form printable pdf download

CCCSB T .G.I.F. P ower C lub A pplication F orm 2 016 -‐ 17

Club m ember I nformation – PLEASE U SE I NK P EN & P RINT

Student’s L egal N ame______________________________________________Date o f B irth _ ______/_______/________ M ale _ ____ F emale_____

Address__________________________________________________________________ C ity______________________State_________Zip__________________

Student’s C ell ( if a ny)_____________________________________ S tudent’s e -‐mail ( i f a ny)_________________________________________________

Parent/Legal G uardian____________________________________ H m P hone ( ________)________________Wk p hone(________)_______________

Cell _ ________________________________________ E -‐-‐-‐Mail A ddress______________________________________________________________________

Grade E ntering, F all 2 016_________________ S chool A ttending, F all 2 016________________________________________________________

IEP S TUDENT? _ ___________ C an p arent v olunteer s upervising k ids 6 -‐7:30pm o n F riday? _ ______________________

Emergency I nformation

Medications s tudent M UST t ake D URING H OMEWORK C LUB h ours _ ____________________________________________________________

Current h ealth p roblems o r a llergies t o d rugs o r f oods ( specify)_________________________________________________________________

IN T HE E VENT O F I LLNESS O R I NJURY D URING H OMEWORK C LUB H OURS -‐ -‐-‐ W here c an s tudent’s p arents/guardian

be c ontacted?

Mother/Guardian_______________________________ D aytime P hone____________________________Cell _ ___________________________

Father/Guardian________________________________ D aytime P hone____________________________Cell _ ___________________________

Emergency C ontact_______________ _ _____________Daytime P hone____________________________Cell____________________________

In t he e vent I c annot b e r eached, p ermission i s h ereby g iven f or t he p hysician o r h ospital d esignated t o p rovide e mergency c are

for m y c hild s hould s erious i llness/injury o ccur d uring s chool h ours. I a lso a uthorize C CCSB t o o ffer c onsent t o m edical a ttention b y

calling 9 11 a nd/or O ffer c onsent a s n eeded.

Physician___________________________________________Address____________________________________Phone_______________________

Hospital____________________________________________Address _ ___________________________________Phone_______________________

We c ertify t hat w e h ave c ompleted t his a pplication a nd t hat t he i nformation g iven i s a ccurate.

Parent S ignature______________________________________ D ate________________________________

Student S ignature____________________________________________ D ate__________________________

For q uestions, p lease c all 3 10-‐326-‐7905 o r e -‐mail t o

Please s end t he c ompleted a pplication t o: C CCSB T .G.I.F. P ower C lub, 2 5420 N arbonne A ve., L omita, C A 9 0717

Chinese Community Church of South Bay

Cccsb T.g.i.f. Power Club Application Form

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