Rehoboth After School Program
Start date: September 24

The Rehoboth After School Program is a FREE program every Monday & Wednesday, 5pm-8pm, designed to provide encouragement and support to youth in grades 7 & 8. Participants will participate in Rehoboth Baptist Church's winter basketball league, engage in educational training time broken up into four sections, and enhance their social skills.

The educational training will include:
-Math & English
-Life Skills
-Law & Justice
-Basketball Skills

Please fill out the application below if you would like your child to be considered for the Rehoboth After School Program. Applicants must have also registered for Rehoboth's winter basketball league in order to be considered.

Student Name (first & last) *
Your answer
Student School Name *
Your answer
Student Current Grade *
Student Age *
Your answer
Student Date of Birth *
MM
/
DD
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YYYY
Student Gender *
Student Address *
Your answer
Student stays with: *
Parent/Guardian Address (if different from student)
Your answer
Mother's Name *
Your answer
Mother's phone number *
Your answer
Mother's email *
Your answer
Father's Name *
Your answer
Father's phone number *
Your answer
Father's email *
Your answer
Which parent/guardian should we contact first? *
Your answer
Does student have access to transportation? *
Do you agree to ensure that your child will be here on time for every day of the program? Unless otherwise prohibited whereas you will inform the Rehoboth Mentor Program. *
List all individuals who are authorized to pick up your child (first & last names required) *
Your answer
List any physical, mental, or emotional limitation your child may have *
Your answer
List any special dietary requirement your child may have *
Your answer
List any allergies your child may have *
Your answer
List any medical needs or conditions your child may have *
Your answer
Emergency Medical Treatment Consent *
I understand, even after reasonable precautions have been taken, activities may involve some risk of injury. I hereby grant permission for Rehoboth Baptist Church to seek emergency medical treatment when deemed necessary. I understand that a conscientious effort will be made to locate me in case of such an emergency. I further agree to pay all fees as it relates to the care of my child.
Child doctor's name & number *
Your answer
General Registration & Liability Waiver *
In consideration for the opportunity to participate in this program of Rehoboth Baptist Church, the undersigned, on his/her own behalf or as parent/legal guardian of the participant, hereby expressly and voluntarily agrees to assume all risks, whether known or unknown. The undersigned, on his/her own behalf or as the parent/legal guardian of the participant, further agrees and covenants, not to sue and to hold harmless and forever release, waive, and discharge the Rehoboth Baptist Church, its legal representatives, successors, agents or employees, from any and all liabilities, claims, demands, actions, causes of action, losses, debts, sums of money, suits and damages, arising out of any injury which the participant and his/her parents, heirs, executors, administrators, successors and assigns, may have sustained by participation in the recreation program or children's ministry of Rehoboth Baptist Church whether caused, in whole or in part, by the acts, omissions, or negligence of the releases or otherwise. I HAVE READ THE ABOVE GENERAL RELEASE AND LIABILITY WAIVER AND UNDERSTAND THAT I FOREVER WAIVE CERTAIN RIGHTS BY SIGNING IT AND DO SO VOLUNTARILY.
Required
Acknowledgement of Non-Licensure *
The Rehoboth After School Program is NOT a licensed program. As such, it is not required to comply with rules and regulations of the Georgia Department of Early Care and Learning - Bright from the Start. This program is a partnership between Rehoboth, the DeKalb County Police Department, and DeKalb area schools. It is not intended to be a child care or group day care facility. By agreeing below, parent/guardian acknowledges and understands that this program is not licensed and is not under the jurisdiction of Bright from the Start.
Required
Parent/Guardian Signature *
Please type your full name here as a digital signature
Your answer
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