Latchkey After-school Registration

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Child's Name

Child's Name *

Date of Birth/Age *

Grade Level/School Name *

Home Address/ City/Zip *

Phone Numbers/Email Address *

Mother's Name/Place of Employment/work number *

Father's Name/Place of Employment/work number *

Emergency Contacts/phone number/relationship *

Allergies/Does your child take medications/What kind *

Doctor Name/Phone number *

Dentist Name/Phone number *

Hospital choice *

In case of emergency, I give my permission that in my absence the personnel of Highland Park Baptist Church Latchkey can provide my child the medical care necessary and also call the EMS if necessary. I also understand that bill for the EMS is the parents responsibility and the church or latchkey will not be liable for the bill. *

Yes

Authorized Persons to pickup my child/Relationship *

Anyone who is NOT authorized to pickup my child (Provide legal documents: restraining order, divorce, custody, etc.) *

I understand that the information on this form may be changed at any time by consulting with the Director of the Latchkey Ministry. This is a Christian Ministry and therefore Bible story, prayer time, music, crafts and etc will be part of our weekly schedule. We strive to teach the children about God's love and his principles for our lives. *

Yes

I understand that this form is not valid until the $60 Registration fee (by June 30th and $75 after July 1st) is paid either by check or cash or money order thru the mail or in person to our office. Days and times are Monday thru Thursday, 8am to 4pm. We DO NOT take credit cards. This fee is non-refundable. *

Yes

I understand that the tuition fee is $60 per child in elementary school, $50 for 2nd child child in elementary in the same family and $45 for 3rd child in same family per week. Middle school will be $50 per week. Payment is due no later than Tuesday of each week with a $10 per day late fee starting on Wednesday. Late fees for late pickup after 6pm is $10 per 15 minutes per child. Also, there is a $20 per week Hold Fee if your child is absent for the week. Payments can be made weekly, bi-weekly or monthly. *

Yes

I understand if my child becomes ill or has a fever above 100 degrees, that I will be called to come pick up my child or will send someone to pick him/her up immediately. *

yes

I/We, the undersigned, sign this release on our own behalf and on behalf of those listed on this application. I/We hereby release Highland Park Baptist Church from risk of illness (including Corona Virus) or injury which may occur at or result from Latchkey or any other Latchkey attendees. I/We understand that I am/We are responsible to notify Latchkey in writing of any allergies or medical conditions of my child and understand that Latchkey is not a medical provider and does not employ a nurse or other trained medical professional. I/We release Latchkey and Highland Park Baptist Church from any claims or causes of action which results from such allergies or medical conditions regardless of the action or inaction of Latchkey staff and volunteers. *

Yes

I prefer my child to do homework at Latchkey as time allows including reading for 20 to 30 minutes and written homework. (This can be changed at any time) All homework is to be reviewed by parents for correctness and signatures. *

Yes

Other:

Required

Thank you for allowing us to serve you this coming school year. We look forward to seeing you and your child.

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