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Children’s Program Registration Form
Step
1
of
3
33%
Child 1
(Required)
First
Last
Gender (Child 1)
(Required)
Male
Female
Date of Birth (Child 1)
(Required)
Month
Day
Year
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
Gender (Child 2)
(Required)
Male
Female
Date of Birth (Child 2)
(Required)
Month
Day
Year
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
Gender (Child 3)
(Required)
Male
Female
Date of Birth (Child 3)
(Required)
Month
Day
Year
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
Gender (Child 4)
(Required)
Male
Female
Date of Birth (Child 4)
(Required)
Month
Day
Year
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
Gender (Child 5)
(Required)
Male
Female
Date of Birth (Child 5)
(Required)
Month
Day
Year
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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 videos and/or photos of my child to be made for the use by Center staff to show area churches and members the ministry work being done. I understand these photos/videos 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
Please note: if your child will have emergency medication left at Friendship House, such as an EpiPen or inhaler, then CLEAR, WRITTEN instructions must be provided.
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)
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