Parent/Guardian Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
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Email*
Confirm Email*
Phone*

1st Emergency Contact - Can't be the parent/guardian above

 

First Name*
Last Name*
Relationship to Child*
Phone*
Street Address*
City*
State*
Zip Code*

2nd Emergency Contact - Can't be parent/guardian above

First Name*
Last Name*
Relationship to Child*
Phone*
Street Address*
City*
State*
Zip Code*

1st Child's Information

First Name*
Last Name*
Date of Birth (mm/dd/yyyyy)*
School enrolled for the 2018/2019 school year*
Name of Teacher*
Does this child have any allergies (food, bees, latex, etc): If so, please specify:*
Does this child take any medication that may need to be administered in an emergency (Epi Pen, inhaler, etc)? If so, please specify:*
Day(s) of the week that this child will not able to attend the After School Program and Reason*

2nd Child's Information

First Name
Last Name
Date of Birth (mm/dd/yyyy)
School enrolled in during the 2018/2019 school year
Name of Teacher
Does your child have any allergies (food, bees, latex, etc): If so, please specify:
Does this child take any medication that may need to be administered in an emergency (Epi Pen, inhaler, etc)? If so, please specify:
Day(s) of the week that this child will not able to attend After School Program and Reason

3rd Child's Information

First Name
Last Name
Date of Birth (mm/dd/yyyy)
School enrolled in during the 2018/2019 school year
Name of Teacher
Does your child have any allergies (food, bees, latex, etc): If so, please specify:
Does this child take any medication that may need to be administered in an emergency (Epi Pen, inhaler, etc)? If so, please specify:
Day(s) of the week that this child will not able to attend After School Program and Reason

After School Agreement with Guardians

  1. I am applying to have my child(ren) attend one of Hartford City Mission's After School programs which meet Monday—Friday from 4pm – 6pm. I understand that placement is restricted to students who are currently enrolled in the 1st – 8th grades, is not guaranteed, and is limited.
  2. I also understand that if my child will be absent from program I must tell/call my child's Site Manager to inform them of the absence before the start of program that day. If I do not do that, it will be considered an unexcused absence.  I understand that Hartford City Mission reserves the right to remove children who are repeatidly accumulating unexcused absences or have an attendance percentage under 80%.
  3. I further understand that my child(ren) may be sent home or removed from the After School Program on conduct deemed to be inappropriate by the staff and volunteers.
  4. I am responsible for getting my child(ren) to and from the program safely.
  5. I understand that the after school program uses lessons that are Biblically-based and that my child(ren) will be exposed to and will participate in Christ-centered activities.
  6. I understand that registration is not complete until I have turned in a copy of my child’s physical from within the last 2 years.

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.

Camp Noah Agreement*
  • Yes

Transportation Release

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.

Transportation Release*
  • Yes

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.

Photo and Video Release*
  • Yes
Additional Comments

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