ABC After School Enrichment Program

ENROLLMENT/REGISTRATION INFORMATION 2023
Entrance to program is based upon availability so space (All applicants will be notified)

Student’s First and Last Name *

First

Last

Student’s ID Number *

Last 4 of SSN *

Student’s Date of Enrollment

Student’s Date of Birth

Student's Age *

Student’s Grade *

Gender *

Race *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Who does your child live with or has custody of the student *

Mother’s Name *

First

Last

Mother's Phone Number

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Mother's Employer

Mother's Work Phone

Father’s Name *

First

Last

Father’s Phone Number

Father’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Father’s Employer

Father’s Work Phone

Kids Hope Alliance will not assume the responsibility of issuing medications to any child/youth. If it is deemed that we are incapable of providing routine, necessary care due to mental or physical incapacity program participation may be denied. I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.

Physician's Name *

First

Last

Physican’s Address

Physician’s Phone Number

Hospital Choice

Please list allergies, special medical or dietary needs, or other areas of concern: Please explain.

Emergency Care plan instructions (if applicable)

Does your child have any behavior issues that we should be concerned about? *

Yes
No

(If "Yes" please, explain)

Is your child currently taking medication to alter or modify behavior and/or mood? *

Yes
No

(If “Yes” please, explain)

Emergency Contacts: Child will be released only to the custodial parent or legal guardian and the persons listen below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached?

Name (Authorized to Pickup 1)

First

Last

Address (Authorized to Pickup 1)

Phone

Name (Authorized to Pickup 2)

First

Last

Address (Authorized to Pickup 2)

Phone (Authorized to Pickup 2)

Name (Authorized to Pickup 3)

First

Last

Address (Authorized to Pickup 3)

Phone (Authorized to Pickup 3)

General Release of Liability:

In consideration of being allowed to participate in any related events and activities the undersigned agrees to the following:

I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions, or negligence, but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) and their volunteers and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in activities through the Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) After-School Program.

I agree that Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) will be held harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of property that may occur to my daughter/son while participating in the Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) After-School Program.

Your initials for General Release of Liability

Authorization for Emergency Care:

In case of accident or serious illness, and the program site is unable to reach me, I hereby authorize Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) to contact the physician indicated on the application and to follow his/her instructions: If it is impossible to contact this physician, Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) may make whatever arrangements necessary to provide care and treatment for my child.

I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions, or negligence, but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) and their volunteers and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in activities through the Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) After-School Program.

In case of accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain in the program, I will be contacted, or transportation arrangements will be made for my child. If the program is unable to reach me, I authorize Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) to contact one of the persons indicated on the enrollment form and ask them to pick up and transport my child home.

Your initials for Authorization for Emergency Care

Photo/Media Release:

I acknowledge and understand that publicity activities such as interviews, photos, and videotaping may occur. I consent and permit my child, as a participant in the Abyssinia Missionary Baptist Church (ABC After-School Enrichment Program) After-School Program and events, to be photographed, videotaped, and/or interviewed for publicity activities.

Your initials for Photo/Media Release

Did you receive a copy of "Know Your Child Care Facility?": Section 7.3, of the Child Care Facility Handbook, requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility” (CF/PI 175-24). Section 2.8, of the Child Care Facility Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the childcare facility.

Yes
No

Parent or Legal Guardian Name *

First

Last