1st Emergency Contact - Can't be the parent/guardian above
2nd Emergency Contact - Can't be parent/guardian above
1st Child's Information
2nd Child's Information
3rd Child's Information
After School Agreement with Guardians
By checking the box below, I permit my child to participate in Hartford City Mission's after school program. Additionally, it confirms agreement with the above statements, that all information provided on this form is complete and accurate, and releases Hartford City Mission (HCM) and all of HCM’s staff/volunteers of any liability.
During the After School Program, your child may go on field trips to various sites within Connecticut. These field trips will enhance your child's learning! All field trips will have an appropriate number of chaperones. Children will be transported in our Ministry Van or vehicles of staff or volunteers whom HCM has run a full driving history on and have also provided HCM with a copy of their current insurance policy. If our trip is in walking distance, we will walk together as a group.
By checking the box below, you have my permission to transport my child in all the above methods. I release Hartford City Misison staff and/or volunteers from any liability.
Photo and Video Release
I understand that Hartford City Mission does not charge a fee for participation in their After School programs. As such, I understand that my child may be photographed or recorded on video to be used for fundraising, memorabilia and future program promotion.
By checking the box below, you have my permission to photograph or videotape my child for inclusion in newspapers or for reasons stated above, or to display samples of her/his work.