2024-2025 Student Application

After School Tuition: $74/Week After School Hours: 3 pm-6 pm (includes one PM snack)

Full Day Tuition: $130/Week ($26/day) Full Day Hours (only on school breaks): 7:30 am-6 pm (includes AM snack, lunch, and two PM snacks)

Registration /Supply Fee: $85 (if your child was enrolled in summer camp, the registration fee is discounted to $35. The student will reuse their Bible, Tshirt, and Sketchbook)

We want all families to be able to afford our center. We are part of the Child Care Payment Program (CCPP) and accept certificates. Click here to learn more about financial assistance and eligibility.

We provide childcare for ages 5-12, K-6th grades. Our activities include Bible lessons, music lessons including guitar (3rd grade and up) or piano (1st grade and up), Skating (parents need to furnish the skates), Arts and crafts, and VBS songs.

To reserve a spot, pre-register BELOW and pay your registration fee. The registration fee is non-refundable. We will not hold a spot for your child until your registration fee is PAID!

We will also need to schedule a face to face interview where parents can tour the facility, as well as sign additional paperwork. You will be asked to provide a copy of your child’s 121 Immunization Form.

Questions or need additional financial assistance? Email to Beth@fishersofmencenters.org

Address:

West Laurel Baptist Church 1400 W 5th Street Laurel MS (behind Walgreens across from Regions Bank)

Group of diverse young students standing together in classroom

2024-2025 Student Application

Student Information. (An Application is required per student.)

If you are enrolling more than one student, you will need to pre-register them individually.

Student Application: Days/Hours of Care needed *

A spot will not be held based on online pre-registration. We will to review and send an invoice. We will need a paid registration fee before a spot is held for the student.

Enrollment Date *

Please list the first date you would like your child enrolled in the center. For after school this date would be the first day of school

Student's Full Name *

First

Middle

Last

Date of Birth *

What age will the student be as of Aug 1, 2024? *

Sex *

Student Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Select Grade for 2024-2025 school year: *

Which School District does your child attend: *

Name of School *

We pickup from North Jones, East Jones, West Jones, South Jones and Glade Elementary. We also pickup from St. John's and Unlimited Christian Learning Center. LCD City Students will ride the school bus over from school.

Tuition Assistance maybe available for parents who meet the income and work requirements for participation in the Child Care Payment Program (CCPP). Have you applied for CCPP? *

CCPP Eligibility Guidelines can be found here: https://www.mdhs.ms.gov/eccd/parent-information/eligibility-guidelines/

What language is spoken by you and your family most of the time at home?

Was your child born in the United States? *

Parent/Guardian Information

Father/Guardian Name *

First

Last

Father's /Guardian Email

Father's/Guardian Cell Phone

Father's/Guardian Place of Employment

Father's Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Father's/Guardian Work Hours

Mother/Guardian Name *

First

Last

Mother's /Guardian Email *

Mother's/Guardian Cell Phone *

Mother's/Guardian Place of Employment

Mother's Employment Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mother's/Guardian Work Hours

Mother's Work Phone *

Medical Information: List any special needs your child may have. *

including skin conditions, asthma, diabetes, epilepsy, seizures

Medical Information: Does your child have any allergies? Please list, including food, if necessary *

For food allergies, we will need a copy of the doctors note of the food allergy to keep on file for the CACFP food program. This is a requirement of their program.

List any Behavioral and Emotional Disorders including ADHD, ODD, Anxiety and other mood disorders *

We do not administer medicine. The child will need to have their medicine before they arrive that day. The parent may come and administer medicine to the student.

List any medicines your child takes daily *

We do not administer medicine. The child will need to have their medicine before they arrive that day. The parent may come and administer medicine to the student.

Behavior at School- Select One *

The center may obtain emergency medical treatment for my child if needed *

Meals Needed: *

After school we only offer a PM snack. For full days/school breaks we serve breakfast, lunch, and two PM snacks.

Please list Home Church and Pastor's Name.

Transportation: I give my approval for Fishers of Men Bible and Music Center to provide transportation for my child including after school pickup and field trips by a licensed driver in a vehicle owned by or operated by Fishers of Men Staff. *

Field Trips: I understand my child maybe traveling on field trips and special activities throughout the enrollment period. *

Field trips will be announced on our monthly calendar and parents will be informed on additional cost.

Skating Consent: I understand that my child will be skating in the gym and waive any claim or cause of action and release liability of Fishers of Men and West Laurel Baptist Church for injuries to my child. I also agree to indemify and hold harmless. *

1. Waive any claim or cause of action against and release from liability the Fishers of Men Bible and Music Centers as well as West Laurel Baptist Church, its officers, board members, employees, and agents for any liability for injuries to my person, my child(ren) or property resulting from my child(ren) use of the facility or participation in the activity listed above; 2. Agree to indemnify and hold harmless the Fishers of Men Bible and Music Center as well as West Laurel Baptist Church, its officers, board members, employees, and agents for any claims, causes of action, or liability to any other person arising from my child(ren) use of the facility or participation in the activity listed above

Child's Tshirt Size (worn on field trips, recital and other events) *

If you just purchased a T-shirt for Summer Camp, your registration fee is discounted and will not include a new T-shirt. New T-shirts will be ordered for new students

My child maybe photographed at the childcare center? *

We are a non profit and need public exposure as well as public donations to cover music lessons and instruments.

Media Release: My child's picture maybe used in media, newspapers, Facebook, etc. *

We are a non profit and need public exposure as well as public donations to cover music lessons and instruments.

How did you find out about our program? *

Emergency Contacts

In case of an emergency and the parents/guardian cannot be reached, please contact:

Emergency Contact # 1-Name *

First

Last

Phone *

Relationship *

Emergency Contact # 2-Name *

First

Last

Phone *

Relationship *

Emergency Contact # 3-Name *

First

Last

Phone *

Relationship *

Pickup- Drop-off List

The following people are authorized to pick-up and drop-off my child. Biological parents are by law able to pickup their child and do not need to be on the pickup list. If there is a custody situation we will need a copy of the court order that says the parent cannot pickup their child.

Pickup/Dropoff -Name#1 *

First

Last

Pickup/Dropoff -Name#2

First

Last

Pickup/Dropoff -Name#3

First

Last

Pickup/Dropoff -Name#4

First

Last

Pickup/Dropoff -Name#5

First

Last

Electronic Invoices *

I agree, I give my permission to send invoices by text or email
I do not and will make other arrangements to make prompt payments

Invoices are emailed weekly or monthly (if you are on CCPP financial aide) and can be paid electronically with debit or credit card.

Electronic Signature to this Application *

I agree, and give my consent
I do not agree

I, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Parent Name (Print) *

Please type your name in this box as your electronic signature.

Parent Signature *

Clear Signature

Date Signed *

42257