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BCAP Application

BCAP APPLICATION

Contact Us

Number of children registering*
Child One
Child Name*
First Last
Nickname
Gender*
Birthday*
Month
Day
Year
Special considerations
- Food Allergy
- Medical Concern
Describe the food allergy or medical concern.*
T-Shirt Size
School name*
Homeroom teacher*
Grade*
Child Two
Child Name*
First Last
Nickname
Gender*
Birthday*
Month
Day
Year
Special considerations
- Food Allergy
- Medical Concern
Describe the food allergy or medical concern.*
T-Shirt Size
School name
Homeroom teacher*
Grade*
Child Three
Child Name*
First Last
Nickname
Gender*
Birthday*
Month
Day
Year
Special considerations
- Food Allergy
- Medical Concern
Describe the food allergy or medical concern.*
T-Shirt Size
School name
Homeroom teacher*
Grade*
Child Four
Child Name*
Prefix First Last Suffix
Nickname
Gender*
Birthday*
Year
Year
Year
Special considerations
- Food Allergy
- Medical Concern
Describe the food allergy or medical concern.*
T-Shirt Size
School name
Homeroom teacher*
Grade*
Child Five
Child Name*
Prefix First Last Suffix
Nickname
Gender*
Birthday*
Year
Year
Year
Special considerations
- Food Allergy
- Medical Concern
Describe the food allergy or medical concern.*
T-Shirt Size
School name
Homeroom teacher*
Grade*
Parent and Emergency Contacts
Parent/Guardian Name #1*
First Last
Parent/Guardian Name #2
First Last
Primary Address*
Street Address City State ZIP Code
Primary Phone*
Alternate Phone
Email*
Physician Name*
First Last
Physician Phone

Emergency Contacts

Provide up to 2 emergency contacts (click plus to add rows)

Name	Phone	Address

Pick-up Authorization*

Additional individuals permitted to pick up child(ren)

Provide up to 5 individuals (click plus to add rows)

Name	Phone

How did you learn about the 21st Century Community Learning Center?
Authorization and Consent
Photography Release

I authorize and consent to being photographed, and to the display, reproduction, alteration or other use of any photographs of me, or in which I may be included with others, in connection with the Birmingham Civil Rights Institute and the BCAP website and press corps contacts.
To the extent that I have any rights, title or interests in the photographs, I assign such rights, title and interests to the Birmingham Civil Rights Institute and BCAP. In giving this permission, without fee or limitation whatsoever, and in consideration of the opportunity to participate in the publications, website, or dissemination of press material, I agree to release, discharge, and hold harmless the BCRI and BCAP and its employees, from any and all claims of libel, or invasion of privacy, arising out of or in connection with the use of my photograph.
Parent/Legal Guardian Signature*
Emergency Release

In the event of an accident which requires medical care, I give my permission, if I cannot be reached, to the attending licensed physician to order and administer medication, anesthesia, or surgical procedure as deemed necessary for the health and safety of my child for which I am parent or legal guardian. I have provided my emergency contact telephone number so that you may notify me immediately should an emergency situation arise. The medical/historical information provided is complete and accurate to the best of my knowledge.
Parent/Legal Guardian Signature*
Liability Release

I do hereby release the Birmingham City Schools, Birmingham Civil Rights Institute, BCAP CLC, its teachers, administrators, agents, partners and employees from any and all liabilities and such personal Injuries as may result directly or indirectly from any activity conducted under the BCAP CLC. I read, understand and affirm the information contained in the registration, photography release, pick-up authorization, and the liability release forms.
Parent/Legal Guardian Signature*
Rules for Safety and Conduct
Download BCAP CLC Rules

I have read, understood, and reviewed with my student the rules of student safety and conduct.
Parent/Legal Guardian Signature*
Date*
MM slash DD slash YYYY