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Please complete all information by printing neatly. Last Name_______________________________Husband__________________Wife___________________ Address: ________________________________________________________________________________ City, State, Zip: ___________________________________________________________________________ Phone(s): _____________________________________ Parent’s E-mail: _____________________________ Local Church Affiliation_____________________________________________________________________ Names, Birth dates and Grades of Children: ________________________ ___/___/___Gr._____ _____________________ ___/___/___/ Gr.______ ________________________ ___/___/___Gr._____ _____________________ ___/___/___/ Gr.______ ________________________ ___/___/___Gr.____ _____________________ ___/___/___/ Gr.______ ________________________ ___/___/___Gr._____ _____________________ ___/___/___/ Gr.______ Emergency Contact: _____________________________________ Phone: ___________________________ How long have you home schooled? __________ Have your children ever been, or are they currently expelled from a public or private school? If yes, please explain (use back if necessary): Have any of your children ever been disciplined by school authorities or been involved in the use of drugs, alcohol, firearms, or knives at school? If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Are you interested in Co-op classes? ___________ What topics would you like to see offered in a co-op class? _______________________________________________________________________________________________ What are your top five activities you are willing to help with to make this group a success? Please label your preferences 1 - 5. __ Calendar planning __ Pictures __ Clean up __ Nursery __ Event planning __ Newsletter __ Website Maintenance __ Cooking __ Teaching __ Crafts __ Other ______________________________ ”By placing my signature below, I confirm that I have read and concur with the WBH By Laws, Policies and Procedures, and Statement of Faith and agree to abide by them. I understand that WBH serves solely as a support group and enrichment workshop program and is not responsible for the education of my children. I understand and agree that it is my responsibility to be aware of and in compliance with the laws governing home educators in the state of North Carolina. I, the undersigned, acknowledge that participation in all activities necessarily involves risk of personal injury. In consideration for being allowed participation in the WBH Workshop program, I hereby release, discharge, and hold harmless WBH and Woodfin Baptist Church, its representatives, teachers, volunteers and members from any claims arising out of, or relating to, physical or other injury that may result while participating in WBH events. I certify that the information above is true.” Signature of Parent or Guardian _________________________________________________________________Date__________________ Payment Received $ ________________ Receipt# ______________ Date ____/___/____ |
Visitor Number 001596
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