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

Parent/Guardian Name

Child's Name

Custody of child:

Yes

This child lives with me at my home address:

Yes

If you answered "Other" above, please specify:

Contact Information

Email address

Mobile Phone

Best way to contact:

Text

Call Mobile Phone

Call Work Phone

Call Home Phone

Home Phone

Work Phone

Home Address

Mailing Address (if different from Home)

Additional Parent/Caregiver

Is there an additional parent/caregiver living in the home?:

Yes

Is at least one Parent/Guardian an active-duty member of the U.S. military?

Yes

Name of additional Parent/Caregiver

Emergency Contacts

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

First Emergency Contact's Name

Relationship

Phone Number

Second Emergency Contact's Name

Relationship

Phone Number

Third Emergency Contact's Name

Relationship

Phone Number

Pick Up Information

Other adults authorized to pick up your child:

First Pick Up's Name

Relationship

Phone Number

Second Pick Up's Name

Relationship

Phone Number

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 Full Name

Child's Preferred Name/Nickname

Child's Date of Birth

Child's Age

Child's Sex

Male

Female

Entering Grade

School

Pick one:

Hispanic

Non-Hispanic

Medical Information

Child's Doctor

Child's Dentist

Does your child have any health concerns (allergies, chronic illness, disabilities, etc.) we should be aware of?

Yes

If you answered yes above, please explain:

Is there anything else you want to tell us about your child?

Notes:

I anticipate that my child will attend Chapel:

1 - 2 times per week

3 - 4 times per week

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.

Agreement

I agree to the statement regarding emergency medical treatment.

I do not agree to the statement regarding emergency medical treatment.

Your Signature

Medication

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.

Permission

I give permission for photos and/or video of my child to be taken by Laughlin Memorial Chapel.

I DO NOT give permission for photos and/or video of my child to be taken by Laughlin Memorial Chapel.

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.

Today's Date

Your Signature

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