Northside After School Program Registration Form

We’re excited that you are interested in the Northside After School Program and look forward to serving your family! After filling out the form below, a $25 registration fee is required to hold a place for your child this Fall. The registration fee may be brought to the church office (241 Northside Dr.) or mailed to the PO address below. Please make checks payable to Milton United Methodist Church. We are happy to answer any questions. Just contact the church office at 608-868-2860 from 8:30 am to 12:15 pm. or send us an e-mail: NISafterschool@gmail.com

Mailing Address: Milton UMC
PO Box 158
Milton, WI 53563-0158

Child's Name (First and Last) *

Your answer

Gender *

Female

Male

Date of Birth (mm/dd/yy) *

Your answer

Grade (2019-2020) *

4th

5th

6th

Student Address (Street, City, State, Zip) *

Your answer

Parent / Guardian Name(s) *

Your answer

Parent Phone Number (best to use) *

Your answer

Parent E-mail (for staff only; will not be shared) *

Your answer

Parent / Guardian Name(s) - 2nd Parent Household

Your answer

Parent Phone Number - 2nd Household

Your answer

Parent E-mail (for staff only; will not be shared) - 2nd Household

Your answer

Emergency Contact - (Name and Phone Number) *

Your answer

Sign-Out Information: Please list 1-2 individuals (other than parent/guardian) who can sign out your child. ***Safety is top priority in the program, therefore no child enrolled will be released from the NIS After School program without a parent/guardian signature or that of one of the individuals listed below. (Note: The names that appear below must be of someone 16 years or older.) *

Your answer

My child is allowed to sign himself/herself out and walk home. *

Yes

Doctor: (Name or Clinic and Phone Number) *

Your answer

Allergies/dietary restrictions or other health concerns

Your answer

Media Policy: Milton UMC, at times, uses media images captured during various activities, events and programs in church-produced materials (Facebook, website, flyers, bulletins, etc.) **Please indicate whether permission is granted for the use of media images that include your family. *

Yes, I give permission for Milton UMC to use media images of my child and my family.

No, I do NOT give permission for Milton UMC to use media images of my child and my family.

Parent Agreement: I understand by submitting this form that I give my child permission to participate in all NIS after school program activities. I will not hold the staff, Milton United Methodist Church or any of its representatives liable for any reason or in the case of accident or injury. I understand it is my responsibility to provide insurance for my child. In the event of an emergency, I give permission to any staff or representative of Milton United Methodist Church to seek medical attention as deemed necessary if I cannot be reached.I understand that I and my child will follow all site rules as laid out in the handbook. I understand that failure to do so may result in being asked to leave the program. I understand I am responsible for the $25 registration fee and per day fee and that these fees are non-refundable. *

Yes

I will... *

Mail in the $25 Registration Fee (Milton UMC PO Box 158 Milton, WI 53563-0158)

Drop off the $25 Registration Fee to the church office (M-F 8:30am-12:15pm)

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