BLEC Healthy Futures Youth Enrichment Program 2026–2027 Afterschool & Summer Camp Registration Proudly Funded by Diabetes Free SC FREE for Eligible Families Serving students from Northside Middle School and East Point Middle Campus only. 1. Program Enrollment Selection Select all programs you wish to enroll your child in: 2026 Fall Afterschool Program August 24 – December 11, 2026 Monday–Friday • 3:30 PM–6:30 PM 2027 Spring Afterschool Program January 25 – May 14, 2027 Monday–Friday • 3:30 PM–6:30 PM 2027 Summer Camp June 7 – July 16, 2027 Monday–Friday • 7:00 AM–4:00 PM 2. Student Information Student Name * Date of Birth Grade School Home Address Parent/Guardian Name * Primary Phone * Email * Emergency Contact Emergency Contact Phone 3. Medical Information Physician Physician Phone Allergies Medical Conditions Current Medications 4. Transportation Authorization My child may ride the school bus from Northside Middle School/East Point Middle Campus to BLEC.My child may be transported home by BLEC if eligible.My child has permission to ride BLEC transportation for educational field trips.My child will be picked up by a parent/guardian. 5. Authorized Pick-Up Please list up to five people authorized to pick up your child. Authorized Person 1 Name Relationship to Child Phone Number Alternate Phone Number Authorized Person 2 Name Relationship to Child Phone Number Alternate Phone Number Authorized Person 3 Name Relationship to Child Phone Number Alternate Phone Number Authorized Person 4 Name Relationship to Child Phone Number Alternate Phone Number Authorized Person 5 Name Relationship to Child Phone Number Alternate Phone Number 6. Parent Permissions I give permission for my child to participate in the BLEC Healthy Futures Youth Enrichment Program. I authorize emergency medical treatment if I cannot be reached. I authorize BLEC and Diabetes Free SC to use photographs and/or video of my child for educational, promotional, website, social media, and grant reporting purposes. I acknowledge my child will follow program rules and expectations. 7. Parent/Guardian Agreement I certify that the information provided is accurate and give permission for my child to participate. Parent/Guardian Electronic Signature * Date Student Electronic Signature Date Questions? Tori Seymour, M.Ed. Project Director Brookland-Lakeview Empowerment Center 1218 Batchelor Street West Columbia, SC 29169 Phone: (843) 478-5175 Email: tseymour@brookland.cc Δ
