Children’s Program Registration – Friendship House Roanoke

Child 1(Required)

First Last

Date of Birth (Child 1)(Required)

Schooling Method (Child 1)(Required)

in-person

virtual

Grade (Child 1)(Required)

School Attending (Child 1)(Required)

Add another child?

Yes

Child 2(Required)

First Last

Date of Birth (Child 2)(Required)

Schooling Method (Child 2)(Required)

in-person

virtual

Grade (Child 2)(Required)

School Attending (Child 2)(Required)

Add a third child?

Yes

Child 3(Required)

First Last

Date of Birth (Child 3)(Required)

Schooling Method (Child 3)(Required)

in-person

virtual

Grade (Child 3)(Required)

School Attending (Child 3)(Required)

Add a fourth child?

Yes

Child 4(Required)

First Last

Date of Birth (Child 4)(Required)

Schooling Method (Child 4)(Required)

in-person

virtual

Grade (Child 4)(Required)

School Attending (Child 4)(Required)

Add a fifth child?

Yes

Child 5(Required)

First Last

Date of Birth (Child 5)(Required)

Schooling Method (Child 5)(Required)

in-person

virtual

Grade (Child 5)(Required)

School Attending (Child 5)(Required)

PARENT/GUARDIAN INFORMATION

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Please note that we MUST have a working telephone number to reach you should a medical or discipline emergency arise. Failure to reach you is cause for review of the child's participation in the program.

Emergency Information

Whom do we call in case of an emergency

Name(Required)

First Last

Emergency Contact 1

Phone(Required)

Emergency Contact 1

Relation to child(Required)

Emergency Contact 1

Name(Required)

First Last

Emergency Contact 2

Phone(Required)

Emergency Contact 2

Relation to child(Required)

Emergency Contact 2

Does your child have permission to walk home?(Required)

Yes

No

Who has permission to pick up your child?(Required)

If someone is picking your child up and is NOT on this form, then you must contact Friendship House in advance. The person picking up your child MUST show staff a picture ID.** Please discuss before activity what the pickup or walk arrangements will be.

Discipline Notification

I agree.

I understand that attendance at the Friendship House is a privilege. I acknowledge the rights of all children enrolled to be in a safe, fun, and ministry-filled environment. Center programs are run by staff and volunteers untrained to deal with severe behavior issues and developmental disabilities. If my child becomes disruptive, disrespectful or uncontrollable to the point that other children are not safe and or cannot enjoy the program, I consent to Center staff following the established discipline procedure in the Code of Conduct.

Sunscreen/Bandages Release

I agree.

Center staff and volunteers have permission to apply sunscreen/bandages to my child when needed.

Photo Release

I agree.

I give permission for my child to be photographed for photos used by Center staff to show area churches and members the ministry work being done. I understand these photos will not be sold or used in any harmful way, but rather to help tell our story and mission.

Field Trip Release

I agree.

I give permission to the Friendship House Roanoke, Inc. to take my child on field trips and be involved in youth and children's activities sponsored by the Center and participating churches. I give permission for the transport of my child to and from events by staff/volunteers in personal or church vehicles. By signing this form, I hereby release Friendship House, as well as its directors, employees, or other agents from all liability or damages for any and all injuries arising from the negligence of any of the above while traveling to this activity via private transportation.

Personal Property, Transportation, Walking Home Release(Required)

I agree.

I understand that the Friendship House Roanoke, Inc. is not responsible for personal property left on the Center property. I also understand that Center staff and volunteers are not responsible for transporting children home or responsible for those that walk home. If my child is not allowed to walk home, I acknowledge that it is my responsibility to have my child picked up on time. If my child is not picked up after 20 minutes of program ending, I understand that Center staff will contact Social Services if I cannot be reached.

School Communication Release(Required)

I agree.

I give permission to Friendship House Roanoke, Inc. staff and interns to be in communication with my child’s teachers, school administrators, and other pertinent school staff regarding my child’s grades, performance, behavior, attendance and other related topics.

Summer Camps and Activities

I agree.

The Summer Program is a long running ministry that is designed for children to learn God's Word and experience His love through Vacation Bible Schools, sports camps, and art camps put on by churches and mission teams. We also take field trips for new experiences and building relationships. Children going into kindergarten through 5th grade or higher when appropriate are eligible to participate. Some weeks however preschoolers are not eligible to come. A preschooler is age 3-5 and must be potty trained to attend.

Medical Release Form

WE HAVE A “NO NIT POLICY” FOR HEAD LICE. YOU NEVER KNOW WHEN THE NITS WILL HATCH OUT. If nits are detected we will send the child home until treated and rechecked before coming back. We also have a NO FEVER/NO SCHOOL POLICY. If your child has a fever, then they are not allowed to return until they’ve been fever-free for 24 hours. Also, if your child misses any part of school due to illness, then they are not allowed to come to the After-School Program. (More details can be found in our Health & Safety Measures Form.)

Family Physician

Phone

Family Insurance Co

Policy #

Does your child have any medical special needs or concerns?(Required)

Yes

No

Has your child had all required shots by the Roanoke City Schools and a record on file?(Required)

Yes

No

Please indicate any health problems and what child it concerns:

Examples: Asthma, Sinusitis, Bronchitis, Hay Fever, Kidney Trouble, Diabetes, Dizziness, HIV/AIDS, Stomach Problems, TB-positive or exposed

Are there any developmental or behavioral issues or diagnoses we should be aware of?(Required)

Yes

No

Please describe the developmental or behavioral issues:(Required)

If your child has any allergies (food, seasonal, medicines, etc.) please describe them below:

Previous operations or Illness

Current Medications

Special Dietary Needs

Such as halal, kosher, vegetarian, lactose-free, etc.

Anything else we need to know?

Verification(Required)

I agree.

I certify that the information on this form is correct. I understand that Center Staff will repeatedly try to notify me during an emergency. If I cannot be reached in a quick manner and or it's a dire emergency, Center Staff and their volunteers may seek appropriate medical care for my child at my expense.

Signature(Required)

Children’s Program Registration Form

PARENT/GUARDIAN INFORMATION

Emergency Information

Medical Release Form

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Friendship House Roanoke

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(540) 343-5437

friends@friendshiphouseroanoke.org

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