Alliance for Family Hope

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I hereby give consent for the following medical care providers and local hospital to be ... Preferred Local Hospital ...
Child’s Name: ______________________________

2017 Gateway 2 Hope After School Program Registration Checklist

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Registration Form (half sheet)

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Emergency Medical Form

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Dismissal Form

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Computer Use Agreement & Photo Release Form (2-sided sheet)

- A registration packet must be completed for each child who attends. CONTACT US: Anita Morrison, Site Coordinator, ([email protected]) Myrna Craig, AFH Community Outreach Director, ([email protected])

Alliance for Family Hope Educate. Encourage. Enrich. 5050 Stanley Ave. Maple Heights, OH 44137 (216) 581-9449 E-mail: [email protected] Website: www.alliancefamilyhope.org

Child’s Name: ______________________________

EMERGENCY MEDICAL AUTHORIZATION FORM Alliance for Family Hope

Child’s Name: ______________________________

Gateway 2 Hope After School Program Date of Birth: ______________ PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured under Gateway 2 Hope After School Program’s authority, when parents or guardians cannot be reached. Information provided on this form will be shared with the program’s personnel who interact with your child to ensure his/her safety at camp unless you note otherwise.

Legal Parent/Guardian (with whom the child lives with) Mother’s Name _______________________________________ Phone: (

) ________-____________

Father’s Name _______________________________________ Phone: (

) ________-____________

Guardian’s Name _______________________________________ Phone: (

) ________-____________

Name of Relative or Childcare Provider: ______________________________ Phone: (

) ________-____________

Address: _____________________________________________________ Street Address Apartment/Unit #

PART I OR II MUST BE COMPLETED PART I - TO GRANT CONSENT I hereby give consent for the following medical care providers and local hospital to be called.

Doctor ____________________________ Phone: (

) ______-_________

Dentist ____________________________ Phone: (

) ______-_________

Preferred Local Hospital ____________________________ Phone: (

) ______-_________

Health Insurance Company _____________________________________ Policy Number _________________________ In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. I also accept responsibility for any necessary expense incurred in the medical treatment of my child, which is not covered by the insurance company listed above. Please list any facts concerning the child’s medical history including allergies, medications being taken, current medical conditions, and any physical impairments to which G2HASP and a physician should be alerted.

_________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________ Date

_______________________________________ Signature of Parent/Guardian

PART II- REFUSAL TO CONSENT I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish for the program’s authorities to take the following action(s):

_________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________ Date

_______________________________________ Signature of Parent/Guardian

Child’s Name: ______________________________

Gateway 2 Hope After School Program Dismissal All participants will be dismissed at 6:00 pm from the program. Please understand that the Gateway 2 Hope After School Program dismisses at 6:00 pm and the children are expected to go straight home or be picked up on time. o I give my son/daughter permission to WALK HOME from Gateway 2 Hope After School Program. __________________ Date

_______________________________________ Signature of Parent/Guardian

o I will be PICKING UP my son/daughter from Gateway 2 Hope After School Program, and do not give permission for he/she to be dismissed until I arrive. __________________ Date

_______________________________________ Signature of Parent/Guardian


The following adults are authorized to PICK UP my son/daughter from Gateway 2 Hope After School Program. _______________________________ _______________________________ _______________________________ _______________________________ __________________ Date

_______________________________________ Signature of Parent/Guardian


Child’s Name: ______________________________

Gateway 2 Hope After School Program Computer Use Agreement Computers and Internet use in Gateway 2 Hope After School Program is a privilege. To use the computers and Internet, you must understand and agree to the information below and sign the agreement. •

I will use the Internet in a responsible manner, respecting the rights of other users.



I will tell my parents or another adult right away if I find something that worries or scares me.



I will get permission from my parent or another adult before giving out personal information such as my address and telephone number.



I will properly use and handle computer equipment and software.



I will refrain from using chat rooms or instant messaging.



I will use proper and respectful language online.



I will only use allowed software and sites.



I will respect the privacy of others’ passwords and files.



I will not look at or search for materials on the Internet that are obscene, offensive, or are connected with gambling.



I will adhere to copyright laws.

PARTICIPANT o I have read and understand the computer use agreement. I understand if I do not follow these rules, I will be not be able to participate in the program. __________________ Date

_______________________________________ Signature of Participant

PARENT/GUARDIAN o I have read and understand the computer use agreement. I understand that any action that goes against these rules may result in the dismissal of my child as a participant in the program. __________________ Date

_______________________________________ Signature of Parent/Guardian

Child’s Name: ______________________________

Gateway 2 Hope After School Program Photo Release Form •

I hereby grant the Gateway 2 Hope After School Program permission to use my child or my child’s likeness in a photograph in any and all of its publications, including website entries, without payment or any other consideration.



I understand and agree that these materials will become the property of the Gateway 2 Hope After School Program and will not be returned.



I hereby irrevocably authorize the Gateway 2 Hope After School Program to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing the Gateway 2 Hope After School Program or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my child’s likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.



I hereby hold harmless and release and forever discharge the Gateway 2 Hope After School Program from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on me or my child’s behalf or on behalf of me or my child’s estate have or may have by reason of authorization.

o I hereby certify that I am the parent and guardian of _______________________________________, and I do herby give my consent without reservation to the foregoing on behalf of this person. I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning, and impact of this release. _______________________________________ Parent/Guardian’s Printed Name __________________ Date

_______________________________________ Signature of Parent/Guardian

Child’s Name: ______________________________

Gateway 2 Hope After School Program Transportation Release Form

This form acknowledges that my child(ren) may ride the Hope Alliance Bible Church Van. Said permission extends to transportation to and from the After School program as well as transportation to and from all Gateway 2 Hope After School Program activities. If and when the behavior of my child(ren) becomes too distracting for the others on or the driver of the van, I acknowledge that she or he will be asked to find other transportation to the church. In consideration of the opportunity for my child to participate and fully recognizing that such as undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless Alliance for Family Hope, Hope Alliance Bible Church, and/or the Christian and Missionary Alliance, nor any of said persons shall be held financial responsible for any injury, illness or death as a direct or indirect result of this activity. We, the undersigned, have read this Release and understand all its terms and execute it voluntarily and with full knowledge of its significance. _______________________________________ Parent/Guardian’s Printed Name __________________ Date

_______________________________________ Signature of Parent/Guardian