Name ___________________________________ DOB ___________________
City _______________________________ State _______________________________
Phone Number ___________________ ________________________
Emergency Contact Information:
Name ___________________________ Number ____________________________
I give permission for my child, ________________________________________, to participate in the Appling Middle School Junior Beta Club. I understand that there is a one time membership fee of $15. I also understand that there will be afterschool activities in which I will be responsible for providing transportation for my child.