After School Registration Form Thank you for your interest in our After School Program. Please complete the following form to register for the 2018-19 school year. Along with the registration form, you will need to pay the $25 non-refundable registration fee. You will have the option to pay online or in person. Step 1 of 4 25% Child's Name* First Last NicknameBirthday* Gender*MaleFemaleGrade*Grade for the 2018-2019 school yearSelect grade12345School*Select schoolAversboroBryan RoadCreech RoadEast GarnerRand RoadSmithTimber DriveVandora SpringsESL Student*YesNoFree/Reduced Lunch*Do you qualify for free or reduced lunch?YesNoAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Allergies?*YesNoIf yes, list allergies*Does your child have ADD or ADHD?*ADDADHDNoMedications?*YesNoIf yes, list medications*Is your child emotionally, behaviorally, intellectually, or physically challenged?*YesNoIf yes, please explain*Does your child have any special circumstances/requests?*YesNoIf yes, please explain*Medical InfoHospital Preference*Insurance Company*Policy NumberParent/Guardian and Pick Up InfoOnly the people listed below will be allowed to pick your child(ren) up.Parent/Guardian #1* First Last Relationship to child*MotherFatherPrimary Language*EnglishSpanishHome Phone #Cell Phone #*Work Phone #Email* Enter Email Confirm Email Parent/Guardian #2 First Last Relationship to childMotherFatherPrimary LanguageEnglishSpanishHome Phone #Cell Phone #Work Phone #Email Enter Email Confirm Email Authorized Pick-up #1 First Last PhoneRelationship to childWould you like to add another authorized pick-up?*YesNoAuthorized Pick-up #2 First Last PhoneRelationship to childWould you like to add another authorized pick-up?YesNoAuthorized Pick-up #3 First Last PhoneRelationship to childWould you like to add another authorized pick-up?YesNoAuthorized Pick-up #4 First Last PhoneRelationship to child Release FormsLiability and Indemnity AgreementI hereby give my permission for my child, named above, to be transported by Community of Hope Ministries on various special event field trips during the course of the summer/track out camp and after school programs. I have been advised that I will be notified of the dates and times of these trips in advance. In consideration of being permitted to utilize the facilities, services and programs of Community of Hope Ministries for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with Community of Hope Ministries, the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into Community of Hope Ministries for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER COMMUNITY OF HOPE MINISTRIES FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILIATED WITH COMMUNITY OF HOPE MINISTRIES, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE Community of Hope Ministries, its directors, officers, employees, and agents (hereinafter referred to as “releases”) from all liability to the undersigned, his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the releasees or otherwise while undersigned is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with Community of Hope Ministries. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned in, upon or about Community of Hope Ministries premises or in any way observing or using any facilities or equipment of Community of Hope Ministries or participating in any program affiliated with Community of Hope Ministries whether caused by the negligence of the releasees or otherwise. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to negligence of releasee or otherwise while in, about or upon the premises of Community of Hope Ministries and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with Community of Hope Ministries. 4. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND IDENMITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of N.C. and that if any portion thereof is invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The provisions of this Agreement shall survive the undersigned’s and Participant’s use of Community of Hope Ministries facilities and equipment and participation in the program, and trips affiliated with the summer camp and after school programs. The provisions of this Agreement shall be binding upon and inure to the benefit of Community of Hope Ministries, the undersigned, the Participant and their respective heirs, personal representatives, successors, next of kin and assigns. 5. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. Signature*I have read and agree to the Liability and Indemnity AgreementSick PolicyWe do not have the facilities necessary to care for sick children at the center. If your child develops symptoms of illness during center hours, you will be contacted to pick up your child. Emergency contacts will be contacted if parents cannot be reached. Parent response is crucial when a child is ill. In emergency instances, 911 will be dialed. Such emergency instances are convulsions, seizures, body temperatures exceeding 103.0, allergic reactions, loss of consciousness, and other life threatening signs. Please understand that this is a measure that may protect the life of a child. Parent/Guardian must complete medical authorization form before staff can dispense any medication to your child. In order to return to the center, the children must be free of symptoms and free of fever for 24 hours without medication. Bringing children to the center that are not well may cause other children to get sick. We follow recommended personal and environmental hygiene practices and have developed this policy to cut down on the spread of illness, and therefore decreasing the number of lost work days for parents/ guardians. Please let us know right away if your children are exposed to or diagnosed with something communicable, such as measles or chicken pox, so we can alert other parents. Children with contagious diseases shall not return to the center until the disease is cured and has been diagnosed and documented by a physician as not being infectious or contagious. This documentation must accompany children on their first day back from being out ill. I understand and agree that neither Community of Hope nor co-sponsoring organizations or their respective chapters, officers, directors, employees, agents, members or volunteers shall assume or have any responsibility or liability for expenses or medical treatment or for compensation for any injury my child may suffer during or resulting from their participation in the program. I also represent and warrant that I have been advised to seek consultation from my child’s doctor about whether he/she can safely participate in the program and whether there are precautions or limitations to my child’s participation.Signature*I have read and agree to the sick policy.Parent/Guardian Consent For Release and Exchange Of InformationThis consent is for the release and exchange of information for the purpose of sharing information on my child’s educational performance in the Wake County Public School System (WCPSS), to include his or her academic achievement and social-emotional development. The purpose of releasing and exchanging this information is to assist individuals to plan and provide a high quality after school educational program for my child. Individuals who WCPSS personnel can share this information in accordance with this release are limited to those involved in implementing Community of Hope Ministries. I hereby authorize WCPSS personnel to release and exchange specified information concerning my child’s educational performance with personnel associated with the above named agency. I understand that this information is to be used by personnel at the agency in planning and delivering educational, social-emotional, and recreational services to my child in the COHM after school program. By signing below I am allowing the following: a. Discussions with my child’s WCPSS school teacher(s) and other staff (e.g., administrators, specialists, counselors), as well as review of surveys about my child completed by these school staff; b. Data on my child’s report card grades, results of End-of-Grade and End-of-Course exams, and other group examinations; c. Other information that may be found in my child’s records at school, including his or her attendance at school and disciplinary incidents at school; The doctrine of informed consent has been explained to me. I understand the nature of the information to be released, the need for this information and use which will be made of this information, and that there are statutes and regulations requiring recipients of this information to maintain the confidentiality of the information and use it only for its intended purposes in the COHM program. I hereby acknowledge that this consent is truly voluntary, and understand the consent will expire automatically on June 30, 2019. I further acknowledge that I may revoke this consent in writing at any time except to the extent that action based on this consent has been taken.SignatureAuthorization for Release and Use of ImageIn consideration of using the services and facilities of Community of Hope Ministries, I hereby irrevocably authorize and grant Community of Hope Ministries the following rights: 1. The right to use the likeness (photograph, picture, portrait, sketches and cartoon, and reproductions of the same, in original or modified form) and/or voice (hereinafter collectively known as “Image”) of the minor(s) whose name(s) appear(s) below (hereinafter collectively known as the “Child(ren)” in connection with its marketing materials or for any other legitimate purpose, with or without using the Child(ren)’s name; 2. The right to use, reproduce, publish, exhibit, distribute, and transmitthe child(ren)’s image individually or in conjunction with other Images or printed matter in the production of brochures, motion pictures, television tape, sound recordings, still photography, CD-ROM, and other media; 3. The right to record, reproduce, amplify, and simulate the child(ren)’s Image and all sound effects produced; and 4. The right to copyright, in its own name, works that contain the child(ren)’s image. I hereby waive the right to inspect or approve the child(ren)’s image or any finished materials that incorporate the child(ren)’s image. I understand and agree that nothing in this release shall obligate Community of Hope Ministries to use the child(ren)’s image and neither I, nor the child(ren) will receive any compensation, now or in the future, in connection with the use of the child(ren)’s image. I hereby release and agree to indemnify, defend and hold harmless Community of Hope Ministries and its directors, officers, agents, and employees from and against any and all claims, demands, liabilities, damages, and cause of action, cost and expenses, including, without limitation, attorney’s fees, of whatever kind or nature arising from Community of Hope Ministries use of the child(ren)’s Image, including, without limitation, all claims for libel, slander, defamation, invasion of privacy or right to publicity and misrepresentation. I agree that all such photographs, portraits, pictures, sketches, cartoons and reproductions as well as all negatives, prints, plates, tapes and disks thereof and all other media containing the images, including, without limitation, the copyrights therein, are and shall remain the sole property of Community of Hope Ministries and it successors and assigns, with full rights of disposition thereof. I understand that the acceptance of this release form by Community of Hope Ministries shall not constitute a waiver, in whole or in part, of sovereign immunity or any other statutory or common law rights by Community of Hope Ministries or its directors, officers, agents, or employees. This authorization and release and the rights granted hereunder shall inure to the benefit of Community of Hope Ministries, its affiliates, successors and assigns, their advertising agency(ies), and those authorized by them. I understand that the child(ren)’s rights to access accommodations and services of Community of Hope Ministries shall not be jeopardized in any way by a decision not to sign this release.SignatureI agree to the release authorization for release and use of image for my child.Camp Good Hope Behavioral GuidelinesOur behavioral guidelines are based on the basic premise of respect. Staff and students are expected to respect each other, and to treat the program, classrooms, and facilities with respect. We have established several specific guidelines for behavior. These guidelines enable all participants in the program to have a safe, enjoyable experience and must be followed in order for students to continue in the program. At camp and in general -Use an “inside voice”. Speak quietly and respectfully. -Refrain from eating, drinking, or chewing gum except in designated areas. -Respect each other! It is never appropriate to make fun of or speak negatively to other after school participants, teachers or guests. -Respect other members’ space, physical person, and property. -Be respectful when the instructor or a guest speaker is talking. -Be positive and try new things. Negative behavior and comments are never appropriate. -Help keep the facilities in order by cleaning up any messes made. -No fighting, violence, or horseplay of any kind. On the Bus -Always enter and exit at the front of the vehicle unless specifically directed to do otherwise in the event of an emergency. -Remain in seat belt, car seat/booster at all times except when entering and exiting the vehicle. -No loud talking, yelling, eating or drinking on the vehicle. -Be respectful of the driver and other passengers at all times. -Follow the driver’s instructions at all times. -Keep hands, feet, and other personal items to yourself. -Do not litter. Consequences of Misconduct -First Incident – Conversation with parents -Second Incident - Meet with Director and parents –warning or one day suspension. -Third Incident – Meet with Director and parents – one week suspension. -Fourth Incident – Meet with Director and parents – permanent removal from program. -Severity Clause: In the Case of Severe Misbehavior such as fighting, threatening other students or staff, possession of a weapon, vandalism or destruction, sexual misconduct, or possession of drugs or alcohol, the student must be picked up immediately and may be permanently removed from the program.Signature*I have read and understand the above guidelines for participation in COHM's After School program. I agree to follow these guidelines and accept responsibility for my actions or my child’s actions. After School Program Parent HandbookHours and Days of Center Operations: The After School Program will open on Monday, September 10, 2018 and will operate through May 17, 2019. Our center will not be open on early release days, teacher workdays, or holiday weeks. A weather emergency or other emergency, which causes school to be canceled, will also result in canceling the after school program. If after school activities for Wake County Schools are cancelled, the Community of Hope After School Program will also be cancelled. Please review our After School calendar to know when the program will be open and closed. Hours of operation: Monday through Friday: 3:15 pm - 6:00 pm. Late Pick Up and Fees: There is a late fee of $1 per minute. This fee will be assessed beginning with the first late pick up. The late fee will be due upon pick-up and can be paid in cash or with a debit/credit card. It is your responsibility to contact your emergency pick-up person if you cannot arrive by the 6:00 pm pick-up time and call the office. Late pick up adversely affects the program since staff must remain until all students are picked up. A student will be suspended from the program at the discretion of the After School Director if late fees are not paid and/or the student is picked up late on more than four occasions. A registration fee of $25 per child is required by Community of Hope Ministries. Attendance: A student must attend the program regularly and consistently. If a student has three (3) unexcused absences in a two-week period, he/she may have their space in the program given to another student. Excused and unexcused absences follow the same criteria as for school. To have an absence considered excused, you must turn in proper documentation to the director (ex: doctor’s note). Students must commit to attending the Community of Hope program all five days of the school week. Students cannot be picked up prior to 5:45 pm. Absences: If your child is at school but will be absent from the program, you must notify the site staff. If a child attended school and is expected to come to the program but is not present, the coordinator will make every effort to notify the parents. The call will alert parents that their child did not attend and will determine where the child is expected to be. This policy is for the safety of the children attending the program. It is important that you discuss with your children the importance of going to the program on days they are scheduled to attend, and that they know which days they are supposed to attend. Your cooperation in implementing this policy is very important. It will allow the staff to identify children who mistakenly get on the bus to go home or go to a friend's house without permission. Because this is a safety issue, parents who do not follow this policy will have their child removed from the program after the third call to locate their children. Children who repeatedly "skip" the program and go elsewhere after school will be dismissed from the program. Staff: We hire passionate, Christian and caring educators who are committed to the program goals of helping students increase their faith while working to increase math and reading scores, to decrease negative choices and increase positive choices, as well as to increase parental involvement. A high quality, faith centered staff is our first priority. All staff members must meet established educational and experience requirements for the position held. Each employee must undergo state and local criminal background checks. Students will be divided into groups according to their grades and development. The student to staff ratio is 1:15. Schedule: Each day’s schedule may include: • Snack Time • Devotional Time • Homework Time • Enrichment Time • Computer Time • Physical Activity Time Food: A snack will be provided daily. Teaching children proper nutrition and manners during snack/eating time is always a part of the program. Homework: There will be a time for homework every week. Students must work on homework during this scheduled time, but may not be able to finish during the time allotted. Staff will be available to answer questions during this time. However, one-on-one tutoring is not available. It is the child’s responsibility to acknowledge his/her assignments and then to pursue the resources available. The staff has no way of knowing what homework, if any, has been assigned to the student. Ultimately, it is the responsibility of the parent to check homework for completion and accuracy Discipline Policies: The desire of the program is never to punish but to guide children to proper behavior through positive techniques. It may be necessary to notify the parent if a child’s behavior is detrimental to the program. Participants will be given one day’s suspension after the first warning and one week’s suspension after the second warning. After the third warning, the participant will not be allowed to return to the program. Parent Involvement: Parents are required to participate and provide input regarding your student’s education. We value your involvement. Please share with your site staff and director any ideas that you may have. We need your support as a team to provide your child with the best service. We want you to know, understand, and discuss with us our goals and we want to know your goals for your child. Parents are always welcome to come in and observe our program. Volunteers are needed; please contact the program director ahead of time so we will be ready for you to help. Family Programs: Family involvement is a key element of programming and may include computer literacy classes, family gardening days, and other family celebrations. Please let us know if you have any suggestions for family programs. Transportation: The After School Program will provide transportation from the schools we serve to our site. A Community of Hope bus will pick your child up at the school and transport them to our program. We coordinate with each school to let them know who is enrolled in our program and they share the information with teachers so they can make sure the students get on our bus. We do not provide transportation home. If Wake County Public Schools has early dismissal for inclement weather or any other situation, the Community of Hope After School Program will NOT be open. Please make sure to pick your child up at school, or arrange for alternate transportation. Health Issues: Staff can only dispense medication to your child if a parent/guardian has completed a medical authorization form. There are some medications that staff will not be able to administer (ex: some medications involving needles). Please contact the program director if this causes any difficulty. If a child is sick when entering the program, as determined by the director or other site staff, the child will be made as comfortable as possible and a parent/guardian will be notified. It is the parent/guardian’s responsibility to pick up their child as soon after notification as the parent can safely travel to the program. Sick children will be separated from the rest of the children as much as possible and will never be left unattended. Staff is trained to recognize communicable diseases and will follow the procedure outlined in First Aid training. Fire Arms/Weapons/Drugs: Our policy regarding firearms, weapons and drugs (alcohol and tobacco) are consistent with Wake County Public Schools. Failure to comply with these standards may include immediate dismissal from our program. Emergency Procedures: If a child has an injury, staff who are trained in First Aid and CPR will attend to the injury. If no further attention is needed, attending staff will fill out an injury report and parents will be provided with a copy of the report. Parents will be asked to sign the injury report and the report will then be placed in the child’s file. If the accident requires attention beyond staff’s training, the child will be transported to the appropriate medical facility as outlined on the enrollment form or 911 will be contacted if necessary. The parent/guardian will immediately be notified. Contact Information: Parents must keep staff informed if their contact numbers change. Arrival and Departure: Procedures for Safe Arrival and Departure of Children – Participants will not be allowed to leave the center with anyone but parent or guardian and those listed on the registration form. Their bus driver will check in your child each day and then you or someone you have designated will sign them out. Always pick your child up from the front lobby – never go to directly to your child’s room. This is to protect all the children and teachers. Parents are required to come in to pick up and sign out their child with a staff member in the front lobby. If members are away from the regular activity area, a notice of their location will be posted on the board. If a parent/guardian either attempts to pick up a child or gives permission for someone else to pick up their child and it is determined by staff in the program, that the person picking up the child is in an incapacitated state (either from drugs, alcohol or any other substance) the child cannot be released to that person. The North Carolina State Highway Patrol or other law enforcement agency will be notified if the person proceeds to take the child. Signature*I have read and understand the policies as outlined in the Community of Hope Ministries After School handbook and will explain all site policies and requirements to my child. I understand that I can request a printed copy of the handbook. I agree to comply with the policies contained in the handbook. Availability & Registration FeeAvailability & Registration Fee Agreement*I understand that my child's enrollment in COHM's After School Program is based on availability of space and payment. I understand that completing a registration form does not guarantee enrollment in the program.I agreeRegistration Fee Payment Method*How would you like to pay the registration fee?OnlineIn Person (cash, check, or card)Product Name* Price: $25.00 Total $0.00 EmailThis field is for validation purposes and should be left unchanged.