Registration Form

CHILD INFORMATION

First Name*

Last Name*

Street Address

Apt.

Home Phone

Cell Phone

Current Grade in School

Age

is child in AVID or Scholars Program?

no
yes

Birth Date (include zeros)

// (mm/dd/yyyy)

Gender

House of worship you attend, if any:

Parent email, if you use it:

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.

PARENT/GUARDIAN INFORMATION

PARENT1 NAME

Parent1 Address

Parent1 Cell

Parent1 Home Tel

Parent1 Work Tel

PARENT2 NAME

Parent2 Address

Parent2 Cell

Parent2 Home Tel

Parent2 Work Tel

EMERGENCY CONTACT (someone else!)

Name Emerg.

Relation

Address (in case we cannot find parent)

Home Emerg.

Cell Emerg.

Work Emerg.

CHILD PICK-UP INFORMATION

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

Pickup1 Name

Relation1

Pickup1 Phone

Pickup2 Name

Relation2

Pickup2 Phone

PERMISSION SLIP & FIELD TRIP FORM

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.

Signature of Parent or Guardian

Permiss Slip Date

CONSENT TO INFORMATION/PHOTO RELEASE

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.

Signature of Parent or Guardian

Photo Release Date

Registration Form

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