Personal Information

ONLY THE PARENT OR LEGAL GUARDIAN MAY REGISTER A CHILD FOR BIBLE RELEASED TIME CLASSES

ALL INFORMATION IS REQUIRED

Name of Parent or Guardian (First & Last Name)        

Relationship to Student        

Parent/Guardian E-mail   

Student's Last Name  

First Name         M.I.

Date of Birth         --------- January February March April May June July August September October November December          -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31          ---- 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

School           ---- Ider Elementary Ruhama Elementary Sylvania Elementary Valley Head Elementary Plainview Elementary Crossville Elementary Moon Lake Elementary Fyffe Elementary Henagar Elementary Geraldine Elementary

Grade         --- 2ND 3RD 4TH 5TH 6TH Teacher   

Has your child ever attended Released Time classes at a different school?         -- YES NO

If so, at what school?         ----- Ider Elementary Ruhama Elementary Sylvania Elementary Valley Head Elementary Moonlake Elementary Plainview Elementary Fyffe Elementary Crossville Elementary Henagar Elementary

Does your child attend church on a regular basis?         -- YES NO

If so, what is the name of the church?

Contact Information

Street Address        

City         State         AL GA TN Zip Code        

Check this box if the mailing address is the same as the street address
 

Mailing Address

City State AL GA TN Zip Code

Daytime Phone         Home Phone        

Emergency Contact (At least one)

Person         Phone        

Person Phone

Person Phone

Please List any health problems or special needs that the above student may have:

I  , request that my child be released from the class period chosen by the school, to attend a Bible Education class offered by Dekalb County Released Time (DCRT). DCRT offers classes without regard for race, religion, sex, national origin, or handicap. All students must have parental permission and be escorted off school property and returned each period by DCRT staff. DCRT carries all necessary insurance and is legally responsible when students leave school property. Classes are offered during the school day but DCRT is not part of the public school. The school does not endorse or oppose DCRT but accommodates the wishes of parents to release their children for its classes. Children will be expected to attend all Released Time classes unless a parent of guardian signs to release them from the program. Children cannot be picked up by a parent or guardian at the Released Time class site.

By submitting this online registration form, I understand that I am the parent or legal guardian of the child being registered. I understand that DCRT has adopted the "Three Strikes You're Out" discipline code and that my child may be removed from the DCRT program for violations. I give permission for my child to participate in entrance and exit evaluation surveys. I hereby give DCRT the right and permission to copyright and/or use, and/or publish, and republish photographic pictures of my child. I also give DCRT permission to transport my child to class in case of rain or inclement weather.

Today's Date         ---- January February March April May June July August September October November December          -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31          ---- 2005 2006