Child Contact Information

Parent Email


If your email is:

You would type:

Confirm Parent*
Child's Phone (Leave blank if child does not have phone or you do not want to share the number)
Birth Date*
Drop Off/Pick Up Information*

Program Attendance

Our after school programs begin at 4:00pm each afternoon Monday - Friday. Camp starts at 1pm each afternoon Monday - Friday. Young Life is on Tuesdays at 6:30pm. Please fill out the below information for your child accordingly.

Days able to attend program*

Medical Information

If your child has any allergies, enter them in the text box. If not, type N/A*
If your child were to come in contact with their allergen, how would you deal with the situation? If your child does not have any allergies, type N/A.*
What medications do your child take? If none, type none.*
What special needs (disabilities, medical conditions) does your child have? If none, type N/A*

School Information

Last Day of School

Summer School Information

If you are signing up for Camp Noah and your child will be in summer school, be sure to fill out this section.

Summer School Times
Summer School Start Date
Summer School End Date

Emergency Contact Information

Anyone listed in this section will have permission to pick up your child and will be contacted in the event that we are unable to reach you.

Primary Parent/Guardian

First Name*
Last Name*
Relationship to Child*

Emergency Contact #1

First Name*
Last Name*
Relationship to Child*

Emergency Contact #2

First Name*
Last Name*
Relationship to Child*

Permissions & Releases

You will be asked to complete this paperwork at your orientation, but we ask that you check each of these boxes now to confirm that you agree.

I give my permission to the school district to release my child's records to Hartford City Mission
I understand my child may be photographed or recorded on video to be used for memorabilia and futur program promotion. You have my permission to photograph and videotape my child or display samples of his/her work.*
I understand that my child may need to be transported to various sites within the state of Connecticut for field trips and other programmatic events. Children will only be transported by licensed staff. I give Hartford City Mission staff and/or volunteers permission to transport my child for program activities and release the staff and/or volunteers from any liability.

Program Agreement

  1. I understand that placement in this program is not guaranteed and space is limited.
  2. I understand that in order for a child to have an excused absence, I must inform the program 1 hour or earlier before program.
  3. I understand Hartford City Mission reserves the right to remove students based on conduct and/or attendance.
  4. I understand that I am responsible for my child's transportation to and from program.
  5. I understand that Hartford City Mission's programs use lesssons that are Biblically based and my child will be exposed to and participate in Christ-centered activities.
  6. I understand that my registration is not complete until all paperwork has been completed and submitted including a physical dated within the last 2 years.
I have read the above agreement and understand and permit my child to participate
Additional Comments


Powered by eTapestry