Community Learning Center Registration Form
Thank you for your interest in having your child attend a Community Learning Center. The Tabernacle, The Art Tatum Zone and our partners are committed to supporting your family during COVID-19 by providing access to internet, meals, quality programming, and caring adults while following CDC and local health guidelines.
Parent's Name *
Child's Name *
Child’s 900#
Child’s Google Classroom Password
Child’s Teacher
Child's Teacher's Email
Child's birthday *
MM
/
DD
/
YYYY
Child's gender *
Second child's name
2nd Child’s 900#
2nd Child's Google Classroom Password
2nd Child's Teacher
2nd Child's Teacher's Email
2nds child's birthday
MM
/
DD
/
YYYY
Second child's gender
Third child's Name
3rd Child’s 900#
3rd Child's Google Classroom Password
3rd Child's Teacher
3rd Child's Teacher's email
Third child's birthday
MM
/
DD
/
YYYY
Third child's gender
Fourth child's name
4th Child’s 900#
4th Child’s Google Classroom Password
4th Child’s Teacher
4th Child’s Teacher's Email
Fourth child's birthday
MM
/
DD
/
YYYY
Fourth child's gender
Clear selection
Grades of your child(ren) (Check all that apply) *
Required
Home School *
Permission for Participation--I give permission for my child to attend the Community Learning Center and to participate in its programming. I hereby release and discharge the Community Learning Center sites operated under the Tabernacle, Day 52 Inc or The Art Tatum Zone, its directors, officers, administrators, volunteers and other parties of every kind of injury incurred by my child while in attendance of the programs. I further agree to hold harmless and fully indemnify Tabernacle and all involved parties of interest from any and all claims, damages, costs, including attorney fees and causes of action, which may arise from any cause of action by me, or on behalf of my child. *
Required
School Release-- I hereby give permission to Toledo Public Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations to better prepare the student for success. *
Required
Please list any allergies and/or dietary restrictions
List any physical or cognitive limitations
Additional medical information
Caregiver Phone Number *
Secondary Phone Number *
Caregiver email address *
Caregiver Mailing Address *
Zip code *
Please identify any other needs of the child(ren) and/or family. (Check all that apply)
When your home school returns to a hybrid schedule, what group will your child(ren) be in? *
Please provide the name and phone number of another individual that is authorized person to pick up children when a primary caregiver can not be reached. Photo identification will be requested before a child is released. *
By signing my full name below, I acknowledge I have read this complete application and this form, and am requesting that my child be admitted as a participant of one of the Art Tatum Zone's Community Learning Centers. *
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