The Backyard Registration, 2017-2018
Children in grades K through 5 are invited to come to The Backyard (an after school program) at the Church of the Covenant. Most weeks we will meet from 4-5:30 pm and on APS early release days we will meet form 1:30-6 pm.

For more information about the program, go to: www.covenantchurcharlington.org/happenings/for-children/wednesday-afternoon.html

Parents registering more than one child, please fill out a form for each child.

After registering, 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 or phone (703-524-4115).

Before your child can attend, you will need to sign a hard copies of your consent, a liability release, a medical treatment permission form, and a photo release. These will be mailed to you and can be returned via mail or in person.

We look forward to seeing your child at The Backyard!

Child's Full Name (and preferred nickname, if applicable)
Your answer
Parents'/Guardians' Names
Your answer
Parent's or Guardian's Email
Your answer
Child's Sex
Child's Date of Birth
Your answer
Name of School that Child Attends
Mailing Address
Your answer
Parent Cell Phone Numbers
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, ADHD, allergies, asthma, diabetes, sensor processing disorder, etc.) If your child has 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, things that upset your child, etc.)
Your answer
Emergency Contact. Please list the name and phone number (must be local) of an emergency contact. Please note that by providing this information, you are giving your permission for your child to be picked up by these individuals (should you be unable to pick your children up).
Your answer
How will your child arrive at The Backyard?
Please list anyone else (besides you and your emergency contact) who you allow to pick up your child from the Backyard.
Your answer
(Optional) Please list the names and ages of other children in your family.
Your answer
(Optional) Do you attend a faith community or church on a regular basis? If so, would you provide its name and location?
Your answer
Please affirm this statement: I want my child to attend The Backyard (after school program) 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 the program runs from 4-5:30 pm. On APS Early Release days, the program goes from 1:30-6 pm.
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