Clone of 2025-2026 Fall After School Registration
  • Format: (000) 000-0000.
  • Do you receive SNAP benefits, medicaid, or within the federal poverty guidelines?

  • This information is for child 1. If you only have one child just skip to the next section after completing this part.

  • *   *        Date of Birth* Grade Level *

  • Does Child 1 have allergies*

  • This information is for child 2.

  •            Date of Birth Grade Level

  • Does Child 2 have allergies

  • This information is for child 3.

  •            Date of Birth Grade Level

  • Does Child 3 have allergies

  • This information is for child 4.

  •            Date of Birth Grade Level

  • Does Child 4 have allergies

  • This information is for child 5.

  •            Date of Birth Grade Level

  • Does Child 5 have allergies

  • This information is for child 6.

  •            Date of Birth Grade Level

  • Does Child 6 have allergies
  • How will your child / children get home?*
  • Do you need Christmas gifts? If yes, come to Jerusalem Baptist on December 20, 2025 from 12-2. The kids must take a photo with santa to receive a gift. First 100 to take photos will receive gifts.
  • Back to School School Supplies
  • Do you have Wifi / Internet at home?
  • Do you have a personal computer or laptop?
  • Would you like to be notified about food boxes if donated (based on availability)?
  • Photo Release Permission (for promotional purposes). This only applies to individual photos.
  • Should be Empty: