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Home-After School Application

APPLY BELOW!

Section 1
BH GIRL INFORMATION
Girl's First and Last Name *
Girl's First and Last Name
Date of Birth *
Date of Birth
Address *
Address
Household Information
Contact Number *
Contact Number
Contact Number
Contact Number
Emergency Contact/Authorized Pick-Up (in addition to names listed above)
Name 1
Name 1
Contact Number
Contact Number
Name 2
Name 2
Contact Number
Contact Number
Name 3
Name 3
Contact Number
Contact Number
Permission to Use Photographs
I hereby give Bernadette’s House, and its employees or agents, permission to take, copyright, use and publish photographs of or concerning me (and/or my children or wards, if under the age of 18) for the purpose of business of Bernadette’s House, including without limitation, the preparation of promotional materials for Bernadette’s House, including materials prepared for the purpose of fundraising.
Mark Yes or No to Photograph usage. *
Health History Application and Waiver of Liability
In order to ensure confidentiality and safety of your child's information, post your online application, you will receive an e-mail with a Health History Form that must be completed by State Law. You will also provide a separate Signature for a Waiver of Liability as well as Permission to Use Photograph. These documents can be e-mailed to info@BernadettesHouse.org, hand delivered to 306 Montgomery Street, Laurel, MD 20707, sent via snail mail to Bernadette’s House, Inc. Suite 171 14625 Baltimore Ave Laurel, MD 20707-4902 or sent by Fax: 1-888-413-1009. NOTE: This Online Form, Medical History Documents as well as Payment confirmation confirm that your Application is complete and your child is ready to start.