Registration Form

Does your child have any special medical or behavioral conditions (i.e. asthma, allergies, diabetes, hyperactivity, attention-deficit-disorder, depression, etc.)? Please list condition, treatment protocol (if any) and related information. 

Who else (besides parents/emergency contact listed above) is permitted to pick up your child, if anyone?

I hereby give my child permission to attend the Abundant Life Tutoring Program, to include any field trips. 

I hereby authorize the staff to provide transportation to and from field trip events that may include transportation in church vans, rented vans, or the staff and volunteers’ personal vehicles.  

I understand that the staff and volunteers will not be responsible for my child(ren) once tutoring and field trips are over.  

I hereby authorize the staff to act for me in securing medical assistance or emergency treatment for my child, if it should become necessary.  

I also authorize the staff to administer medication(s) to my child if needed; these medications may include but are not limited to Tylenol, antibiotic ointments, Benedryl cream, Pepto Bismol, and Hydrocortisone Cream.  

With this, I release Charlottesville Abundant Life Ministries, their staff and volunteers, from any claims or liabilities resulting from injuries that may be sustained or medical treatment received.  

I understand that my child may be photographed or video-taped during special events or daily activities of the Abundant Life Tutoring Program. I consent to the use of any and all pictures or videos in a promotional or educational context. 

I authorize the release of my child’s first name and grade in the caption or description of the picture. I understand that all pictures will be displayed in a tasteful manner, and will be used only in accordance with the values of Charlottesville Abundant Life Ministries (CALM).