Registration Forms
 Share
The version of the browser you are using is no longer supported. Please upgrade to a supported browser.Dismiss

View only
 
ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
2
School LYNC
3
4
Family Name:__________________________________________________________________
5
6
Mother's Name:_______________________________
Father's Name:_________________________________
7
Mother's Address:_____________________________
Father's Address:_______________________________
8
City/State/Zip:________________________________
City/State/Zip:__________________________________
9
Mother's Phone:_______________________________
Father's Phone:_________________________________
10
Mother's Employer:____________________________
Father's Employer:_____________________________
11
Work Phone:_________________________________
Work Phone:__________________________________
12
13
14
Step - Mother's Name:_______________________________
Step - Father's Name:_________________________________
15
Step - Mother's Address:_____________________________
Step - Father's Address:_______________________________
16
City/State/Zip:________________________________
City/State/Zip:_________________________________________
17
Step - Mother's Phone:_______________________________
Step - Father's Phone:_______________________________
18
Step - Mother's Employer:____________________________
Step - Father's Employer:_____________________________
19
Work Phone:_________________________________
Work Phone:___________________________________
20
21
In case of an emergency, whom should we contact first?_____________________________________________
22
Phone:___________________________________
23
Please list at least one additional emergency contact person ( other than yourself ) and phone number:
24
25
26
27
See attached sheet for cost for each plan.
28
29
Plan A - Full time care - before school AND after school care.
30
Plan B - Half time care - before school OR after school care.
31
AMor PM
32
Please check one.
33
34
Plan C - Drop in care. Care for 2 hour delays, early dismissals, snow days, and vacations.
35
36
37
Liability / Medical Release
38
In consideration of being accepted by Jefferson Community Church for participation in LYNC, I / we being the parents /
39
legal guardian of:______________________________________________________, do release and agree to hold harmless
40
Jefferson Community Church and the directors thereof from any and all liability, claims, or demands for personal injury,
41
as well as damage and expenses, of any nature that may be incurred by the parent/legal guardian and child-participant
42
while the child is participating in program.
43
I/We, on behalf of our child-participant, assume all risk of personal injury, damage, and expense as the result of partici-
44
pation in recreational activities involved. Authorization and permission are given to said church to furnish any necessary
45
transportation, food, and lodging for our child-participant.
46
I/We, as parents/legal guardians of the child-participant give our permission for him/her to participate fully in all
47
activities. We give our permission to take said participant to a doctor or hospital and authorize medical treatment, including
48
but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. We
49
understand that we will be contacted if at all possible, but in the event that we cannot be reached, the director and /or
50
other staff may choose a reputable physician.
51
Should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we
52
assume all transportation costs.
53
I give permission for my child's picture ( but no identifying information ) to be used in publicity for LYNC, which may in-
54
clude, but is not limited to, publication on the church website.
55
I further give permission for release of information regarding my child between Jefferson Community Church, LYNC
56
staff and my child's school _____________________________________ (name of school).
57
58
I also assume all financial liability for the child care costs.
59
If this cost is to be split between parents, please request financial responsibility paperwork.
60
61
Parent or Guardian Signature
Parent or Guardian Printed Name
62
63
64
65
66
67
68
Child's Information
69
Please complete the section below for each child who will be attending LYNC this school year.
70
71
Child's Name:__________________________________
Gender:
Male or Female
Age:_________
72
73
Birthdate:_____________________________________
School:____________________________________________
74
75
Grade: ( School year 2019 - 2020 )_______________________________
Teacher:___________________________________________
76
77
78
79
Does your child have an Individual Education Plan ( IEP ) or a 504 on file with the school?
80
81
Are there current court orders related to the custody of your child?
YesNo
82
If yes, please provide documentation.
83
Are there any current legal documents (i.e.court orders) that restrict a named person from having access to your child?
84
85
YesNo
86
If yes, please provide documentation.
87
88
Please list any additional information that you feel the LYNC staff would need to know about your child as well as the
89
most important behavioral, social, and emotional areas you would like to see your child work on.
90
91
92
93
94
95
96
Child's Information
97
Please complete the section below for each child who will be attending LYNC this school year.
98
99
Child's Name:__________________________________
Gender:
Male or Female
Age:_________
100
Loading...