Name

First Name

Last Name

Gender

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Age

Grade (2024-2025)

School

Parent/Guardian Contact Information

Child Lives With

Parent/Guardian #1

First Name

Last Name

Mr.

Mrs.

Ms.

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Daytime Phone

(###)

###

####

Parent/Guardian #2

First Name

Last Name

Mr.

Mrs.

Ms.

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Daytime Phone

(###)

###

####

Emergency Contact Information – Alternate Pickup/Release

Emergency Contact #1

First Name

Last Name

Daytime Phone

(###)

###

####

Cell Phone

(###)

###

####

Relation To Child

Emergency Contact #2

First Name

Last Name

Daytime Phone

(###)

###

####

Cell Phone

(###)

###

####

Relation To Child

Please list additional persons who are permitted to pick up your child

Medical Release Information

Health Insurance Provider

Health Insurance Policy #

Primary Physician

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Hospital Preference

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). Also list any required treatments and if paramedics should be called.

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes

If yes, explain

Is your child allergic to any type of food or medication?

Yes

If yes, explain

Does your child require a special diet?

Yes

If yes, explain

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Parent/Guardian Initials

I understand that the Congaree Complex CDC and Red Hill Baptist Church will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Parent/Guardian Initials

Please check how you heard about the Congaree Complex CDC Congaree – After-School Program

Website

School

Flyer

Word of Mouth

Other

Terms of Agreement

PHOTO RELEASE: I hereby give permission for my child to be photographed during the Congaree Complex CDC Congaree – After-School Program. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Congaree Complex CDC and Red Hill Baptist Church.

Parent/Guardian Initials

TRANSPORTATION RELEASE: I hereby give permission for the transportation of my child for official Congaree Complex CDC and Red Hill Baptist Church Congaree – After-School Program activities by modes of transportation agreed to by the coordinators.

Parent/Guardian Initials

Congaree Complex CDC and Red Hill Baptist Church and its co-organizers are not responsible for lost or damaged personal property. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Name of Parent/Guardian

First Name

Last Name

Date

YYYY

Thank you for registering! Your form has been submitted and you will be contacted with further instructions and details.

AFTER-SCHOOL PROGRAM
REGISTRATION FORM

For questions or concerns, contact Ernestine Reese at congareecomplexcdc@gmail.com or 803-206-8617

AFTER-SCHOOL PROGRAMREGISTRATION FORM

For questions or concerns, contact Ernestine Reese at congareecomplexcdc@gmail.com or 803-206-8617

AFTER-SCHOOL PROGRAM
REGISTRATION FORM