Registration for The Backyard: Wednesday Kid's Club, 2016-2017
Children in grades K through 5 in Arlington are invited to come to The Backyard: Wednesday Kid's Club at the Church of the Covenant. Most weeks we will meet from 4-5:30 pm and on early release days we will meet from 1:30-5:30+ pm (the + is for special nights that include a dinner for parents and children).

Parents registering more than one child, please fill out a form for each child. (Sorry for the inconvenience).

Child's Full Name (and preferred nickname, if applicable)
Your answer
Child's Sex
Child's Date of Birth
Your answer
Elementary School that Child Attends
Your answer
Grade in School for the 2016-2017 School Year
Your answer
Parent(s) or Guardian(s) Name(s)
Your answer
Parent(s) or Guardian(s) Email(s)
Your answer
Complete Mailing Address
Your answer
Dietary restrictions
Does your child have any physical, mental, or behavioral issues that we would need to be aware of as we plan activities? (For example, but not limited to, AD/HD, allergies, asthma, diabetes, sensory processing disorder, etc. If you child has any allergies, please list them as well as the severity and type of reaction.)
Your answer
Is there anything else about your child that you would like us to know (e.g. custodial arrangements, persons to whom your child should NOT be released, things that upset them)?
Your answer
Emergency Contact: Name and Phone Number (must be local)--Please note that by providing this information to us, then you are giving your permission for your child to go home with these individuals (should you be unable to pick them up).
Your answer
How will your child arrive at The Backyard?
How will your child depart?
If you will be using a designated adult (either for drop-off or pick-up, even only occasionally), please list the designated adult's name and phone number (cell preferred). Please note, by listing this person's name, you are giving your permission for your child to be dropped off and/or picked up by this person.
Your answer
(Optional) Please list the names and ages of other children in your family
Your answer
(Optional) Do you attend a faith community on a regular basis? If so, would you provide its name and location?
Your answer
(Optional) Would you be willing to volunteer with this program? If yes, how? (i.e. attending a weekly meeting, providing snacks, sharing a special talent, etc.)
Your answer
Permission for Your Child to Attend
Yes, I want my child to come play at The Backyard: Wednesday Kids' Club at the Church of the Covenant (2666 Military Road, Arlington, VA 22207) on select Wednesdays throughout the 2016-2017 school year to have fun, grow, and learn together with other people of faith. Most weeks we will meet from 4-5:30 pm. On early release days, we will meet from 1:30-5:30 (or later, if a dinner is involved).
Your answer
Next Steps
Thank you for registering your child for The Backyard: Wednesday Kids' Club! you will receive an email from Campbell Hackett, Christian Educator at the Church of the Covenant (email: campbellatcovenant@gmail.com). This email will confirm your registration and provide more information about the program. If you have any questions, please contact Campbell via email (campbellatcovenant@gmail.com) or phone (703-524-4115, during business hours).

Before your child can attend, you will need to sign a hard copy of your consent, liability release, medical treatment permission, and photo release.

We look forward to seeing your child at The Backyard!

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