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Laughlin Afterschool Program Application

Please fill the following form in its entirety if you'd like to sign your child up for the Afterschool Program. You must be the parent/guardian of the child in order to fill this in.

Parent/Guardian Information - Person completing this application

Child's relationship to me:
Custody of child:
This child lives with me at my home address:

Contact Information

Best way to contact:

Additional Parent/Caregiver

Is there an additional parent/caregiver living in the home?:
Is at least one Parent/Guardian an active-duty member of the U.S. military?

Emergency Contacts

NOTE: Must be available during afterschool program, 3:00 - 6:00 PM

Pick Up Information

Other adults authorized to pick up your child:

By legal/court order, the person(s) named below is not permitted to pick up my child and/or have contact with my child. Any changes in custodial arrangements must be submitted as a written, signed document.

NOTE: Changes in contact information, emergency contact information, pick up information, etc. must be communicated to the Chapel. Changes in pick up/drop off locations must be submitted in writing.

Child Information

Child's Sex
My child identifies as:
Pick one:

Medical Information

Does your child have any health concerns (allergies, chronic illness, disabilities, etc.) we should be aware of?
I anticipate that my child will attend Chapel:

Medical Release

I understand that Laughlin Memorial Chapel is not a medical facility and that they do not have licensed medical professionals on the premises. I understand that my child will be properly supervised during activities but that sometimes, accidents do occur. I understand that medical and/or hospital care will be sought if a serious injury or illness develops while my child is at LMC. I also understand that Laughlin Memorial Chapel does not have medical insurance coverage on my child. The cost of emergency medical transportation and/or treatment is solely my responsibility. I will not hold Laughlin Memorial Chapel, its Board of Directors, its staff, its volunteers or its supporters liable for accidental injury, illness or death. I have informed Laughlin Memorial Chapel about all medical conditions and/or allergies relating to my child. I further understand that in the case of serious injury or illness attempts will be made to notify and/or those I have listed as emergency contacts. If it is not possible to contact me, I give my permission for emergency treatment or surgery as recommended by any qualified medical facility or personnel. By signing below I am confirming that I have read this and that the bubble I select under the "Agreement" text below is my choice regarding this medical release.



I understand that Laughlin Memorial Chapel is not permitted to dispense medication of any kind (over the counter or prescription) to my child at any time. Please do not send medication to the Chapel with your kid.

Policies for Chapel Participation

1. Updated contact information (home phone, cell phone, address, etc.) must be on file with the LMC office.

2. Changes to arrangements for pick-up or drop-off of children must be made in writing and be signed and dated by the parent or guardian.

3. Any message you may have for your child can be phoned into the Chapel and left with whoever answers the call.

4. Children are not permitted to use cell phones, tablets or other electronic devices while participating in Chapel activities unless furnished for the learning environment.

5. The Chapel fosters respect for people and the learning environment. Violence, vandalism, theft, bullying, disruptive/unsafe behavior, bad language - at the Chapel, on the bus, or at off-premise activities -- will result in disciplinary action.

Media Release

I understand that, with my permission, Laughlin Memorial Chapel may use photos and/or video of my child, named on this application, taken during LMC activities for promotion and publicity of Laughlin Memorial Chapel programs. These photos and/or video may be used in publications of the organization, posted to the Laughlin Memorial Chapel website, posted on social media sites operated by Laughlin Memorial Chapel and/or released to the news media for use in articles or news stories about the organization and/or to be used in promotional advertising for the organization on television or in other media. I understand that these photos and/or video are the property of Laughlin Memorial Chapel and may be used by them for the purposes of promotion and/or news stories for an indefinite period of time. I will in no way expect or accept payment or royalties for use of these photos and/or video.  I understand that I may revoke this permission at any time by giving written notice to Laughlin Memorial Chapel, PO Box 6195, Wheeling, WV 26003.


Sickness Policy

The Chapel will follow recommendations of the CDC and practices of the school district regarding any contagious illness. Children showing symptoms such as cough, shortness of breath, fever, chills, muscle pain, sore throat, lost of taste/small, nausea, vomiting, or diarrhea should not attend Chapel. 

Parent/Guardian Signature

By my signature I agree that I have reviewed all information in the application regarding transportation, policies, conduct, media participation, and medical care. I give permission for my child, named on this application, to participate in the Chapel afterschool program.

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