Student First Name: Student Last Name:
Name of the School your child attends: Grade: Room
My child, (Student's Name) has my permission to be escorted and transported if necessary after school for one hour each week to receive religious instruction at a nearby church or designated teaching site from a teacher provided by the Released Education program of Long Beach/Bellflower.
My student is enrolled in the after school daycare at:
Parent / Guardian: Phone:
Emergency Phone:
Home Address:
City: State: Zip:
*School assumes no responsibility for the program.
Upon receiving registration, a hard copy will be mailed to the address provided to obtain a parent signature. Please call Sally Atkinson at (562) 428-7733 with any questions or concerns.
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