Loading… BROTHERS AND SISTERS EMERGING 5315 HILLCREST STREET PITTSBURGH, PA 15224 PHONE: 412-404-2250 B.A.S.E. Program Participant Information FULL NAME Last name First Name PARENT / GUARDIAN'S NAME Last Name First Name Street Address City, State Zip Day Time Phone: Cellphone Number: E-Mail Address Work Phone School/Grade Birth Date I hereby give permission to the Brothers and Sisters Emerging to share information on my child with funders, emergency care providers, counselors, medical professionals, schools, and other human service agencies on an as-needed basis. All information will be kept strictly confidential. Afterschool Program Code of Conduct I will follow the program schedule. I will not bring only the listed items to program (no weapons, etc.). I will respect program staff, directors, and other participants by not using foul language, name calling or fighting. I will follow all safety rules set forth by the program staff. Type In Your Name As Your Signature Date I agree to help my child abide by this code of conduct. Type In Your Name As Your Signature Date How did you hear about our afterschool program? Send
