CrossOver After School Program 2018-2019 Registration
Registration for returning CrossOver students will begin Monday, February 5th.
Beginning Monday, February 19th registration will be open to DPUMC church family and Week Day School students that will attend SJE.
If there are any remaining spots they will be offered to the public after Spring Break.
***Please note filling out the registration forms does not automatically secure a spot in our after school program. You will be contacted with further information***
Child's Name *
Your answer
Child's Date of Birth *
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Child lives with: *
Your answer
Mother or guardian's name *
Your answer
Mother or guardian's Address (please include street #, street name, city, state & zip code) *
Your answer
Mother guardian's place of employment
Your answer
Mother or guardian's Email Address *
Your answer
Mother or guardian's Work Phone *
Your answer
Mother or guardian's Cell Phone *
Your answer
Mother or guardian's Marital Status *
Mother or guardian's Spouse's name
Your answer
Father or guardian's Name *
Your answer
Father or guardian's Address (please include street #, street name, city, state & zip code)
Your answer
Father or guardian's Place of Employment
Your answer
Father or guardian's Email Address *
Your answer
Father or guardian's Work Phone *
Your answer
Father or guardian's Cell Phone *
Your answer
Father or guardian's Marital Status *
Father or guardian's Spouse's Name
Your answer
In the event of an Emergency, who would you like us to contact first? *
Your answer
In the event of illness or an emergency and parents cannot be reached, the following person may be contacted to pick up my child. The following person may also pick up my child after picture ID is verified and noted by a CrossOver Employee. **Please list Name, Relationship to child and Phone Number and Address (please include street #, street name, city, state & zip code) of person #1 to contact *
Your answer
In the event of illness or an emergency and parents cannot be reached, the following person may be contacted to pick up my child. The following person may also pick up my child after picture ID is verified and noted by a CrossOver Employee. **Please list Name, Relationship to child and Phone Number and Address (please include street #, street name, city, state & zip code) of person #2 to contact *
Your answer
In the event of illness or an emergency and parents cannot be reached, the following person may be contacted to pick up my child. The following person may also pick up my child after picture ID is verified and noted by a CrossOver Employee. **Please list Name, Relationship to child and Phone Number and Address (please include street #, street name, city, state & zip code) of person #3 to contact
Your answer
Who CANNOT pick up your child?
Your answer
May your child be released to the care of a sibling under the age of 18 years old. (You must list the sibling as an Emergency Contact.) *
My child attends San Jacinto Elementary at 1302 East 13th St. Deer Park, TX 77536 *
Grade for 2018-2019 school year *
Your answer
His/Her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. *
Vision and hearing screening are on file at school. *
I understand that CrossOver ASP does not provide field trips. *
I understand that CrossOver ASP does not provide opportunities for swimming in pools or wading pools. *
I give permission for my child to watch G and PG rated movies. I understand that the program does not routinely show movies to my child and a movie day would be considered a special treat. *
I give permission to CrossOver ASP staff to pick up my child from San Jacinto Elementary and walk with my child across the street to arrive at the CrossOver ASP. *
I understand that my child will be given snack while in care at CrossOver ASP. Please share any food allergies in a later entry when asked. *
I hereby grant permission for my child's photograph to be used b y CrossOver for: Presentations used by the program and/or church. *
Required
I hereby grant permission for my child's photograph to be used b y CrossOver for: The church website or the program web page, including church Facebook page. *
I hereby grant permission for my child's photograph to be used b y CrossOver for: School displays, scrapbooks, newsletters, articles or programs. *
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to the following medical care facility: *
Your answer
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to the nearest medical facility available. *
Child's Primary Physician Information: Name of Physician *
Your answer
Child's Primary Physician Information: Physician Address *
Your answer
Child's Primary Physician Information: Physician Phone Number *
Your answer
I give consent for the facility to secure any and all necessary emergency medical care for my child. *
Please list any medications prescribed for your child for long-term continuous use:
Your answer
List any important information that will help us in caring for your child, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, and any other information which caregivers should be aware of. If there are non please indicate NONE. *
Your answer
My child has known allergies *
If "YES", please list each allergy, what your child's reaction to this allergy is and how your child is treated for this allergy:
Your answer
I give permission to CrossOver ASP to post my child's name, birth date, and any known allergies in his/her snack room so that all staff involved in the care of my child may observe it. *
I have received a copy of the facility's operational policies including those for disciple and guidance. *
I will abide by all guidelines and procedures found in the facility's operational policies. *
I understand that there is a $75 non-refundable registration fee that must be paid along with a completed enrollment form before my child is completely enrolled in the program. *
By digitally signing this document you are affirming that your responses are accurate and truthful to the best of your knowledge. Please type your name below. *
Your answer
Today's date *
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