Appling Middle School Junior Beta Club

1210 Shurling Drive œ Macon, GA 31211 œ 478-779-2200

Information Sheet

                              Grade __________________

                      Supervision ___________________

­­­­­­­­­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.

________________________________________________

Parent Signature