After School Registration

***Please Note: All children entering grades 1-8 who live or go to school near Good Shepherd UMC are welcome to attend the After School Program. Walking pick-up is provided from Hampden Elementary/Middle School as a courtesy. Other students must provide their own transportation to the program. If they arrive to the Church before the larger group (approximately 3pm), we are not responsible for their actions or safety. Please ensure your child has proper supervision.

Parent/Guardian Information

Health Information (Will be stored confidentially)

Please describe any health or medical conditions that our staff should be aware of when working with your student or in the case of emergency *

Food Allergies (Please list) *

Medical or Non-food Allergies (Please list) *

Is your student CURRENTLY taking any medication? *

Yes No

Current Medication (Please list) *

Please list any medication your student will be bringing WITH THEM to the program (such as an inhaler). NOTE: Good Shepherd Staff are NOT responsible for administering ANY medication *

Physician Name *

First

Last

Physician Phone Number *

Physician Address *

Line 1

Line 2

City

State

Zip Code

Country

Insurance Information *

My child does not have insurance. (Please enter "N/A" in the rest of the blanks)

Insurance Carrier *

Policy Number/Group Number *

Name of Insured *

First

Last

Employer/Group Name *

Name on Insurance Card *

First

Last

***Please Note: We require a separately signed "Permission to treat and transport" form that will need to be signed the first week of the program. If you check the "no insurance" option, we will call you to discuss emergency procedures.

Photo/Media Release

I hereby give permission Good Shepherd UMC, to photograph and/or videotape the student for educational or promotional purposes.
By selecting the button below, and typing my name and date, I understand that this serves as my electronic signature, with the same authority and use as my actual signature.

Signatures

By electronically signing below, I attest that the information contained on this form is accurate to the best of my knowledge and ability. I understand that this is an application and registration form, but that registration is NOT complete until ALL waivers are signed in hard copy (including Permission to Treat, Permission to Transport, Waivers of Liability, and Student Code of Conduct).

I also understand that while the following does not represent an exhaustive list, a student may be immediately dismissed from the program for the following reasons:
-Leaving the site or established boundaries;
-Bringing a weapon (defined as any object designed, used for, or capable of inflicting bodily harm or physical damage); alcohol; drugs; or any illegal substance to the program; a firearm; explosives; or anything else deemed inappropriate by the staff or volunteers;
-Inappropriate interaction (physical or verbal) from the participant and/or their parent(s)/guardian(s) with staff, volunteers, or any other program participant's (parent(s), guardian(s), and/or students); and
-Striking or hitting an employee, volunteer, or participants.

If the program fills to capacity, I understand that I will be notified as soon as possible so that I can make other arrangements for my student.

I also agree to update the staff with any changes to the information I've provided in a timely manner.

Additionally, I understand that this is a free program, provided as a ministry outreach of Good Shepherd United Methodist Church. We will be asking families to contribute to the program with snacks, supplies, or a donation to help purchase these items so that we can keep this program sustainable and available for the foreseeable future.

NOTE: As of 5 September 2017, our After School Program is filled to capacity. By submitting this form, I understand that I am being placed on a waitlist in the event a space opens up.

Participant's Information

Parent/Guardian Information

Health Information (Will be stored confidentially)

Photo/Media Release

Signatures