City on a Hill Youth Registration Form 1

Your youth has registered for City on a Hill programs. Please fill in the information below so they can attend the activities we offer.

Youth Program Guidelines:

1. Youth will NOT be allowed entry into the program until a completed/signed registration form is returned by a parent/guardian.

2. Zero Tolerance Policy: Violating the Zero Tolerance Policy will result in immediate dismissal from the program and possible criminal charges. Parents will need to provide immediate transportation from the program in the event of dismissal.
A. The possession of or threat of use of weapons.
B. Bullying, fighting, and overtly aggressive behavior.
C. The use of tobacco products, alcohol, drugs, or fireworks on the property.
D. Theft or intentional destruction of property.

3. Spring Weekly Youth Center program hours are Mondays through Thursdays from 3:00 pm - 6:00 pm. Wednesdays and Thursdays are for teens only. Parents picking up children must pick them up no later than 5:55 p.m. at 940 N. 23rd St.

4. To ensure the health and safety of the children, if a youth is sick or has any symptoms that indicate a certain illness, he or she may not attend City on a Hill youth programs and will be sent home immediately.

PARENTAL PERMISSION AND RELEASE:
EMERGENCY MEDICAL RELEASE: In case of emergency, I give City on a Hill representative's permission to render first aid and/or seek treatment for my child in a medical care facility; I give the medical care provider permission to administer the necessary treatment, and I accept full financial responsibility for any services rendered.
MEDIA RELEASE: By signing below, I give permission to City on a Hill to include photographs/videos of my child in promotional materials (including the organization's website and social media) used to increase awareness of City on Hill programs.
LIABILITY RELEASE: By signing below, I absolve City on a Hill of any responsibility for any accident or injury to my child or caused by my child to others where neglect is not involved. Furthermore, I understand that City on a Hill can only be responsible for my child during days and times that he/she has been check-in and that City on a Hill will not be responsible for my child when he/she is traveling or walking to and from any City on a Hill activity.
PROGRAM GUIDELINES: I acknowledge that I have read and agree to the above Program Guidelines that City on a Hill has established.
***Initial here: * Date: Date*
I give my permission for my child(ren) to participate in the Children and Youth Programs at City on a Hill and will encourage my daughter/son to attend regularly and adhere to the guidelines and procedures of the program(s) my child is registered for.

Parent / Guardian Information:

Primary Parent/Guardian's First & Last Name:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ethnicity:*

Hispanic*

Gender:*

Relationship to Child:*

All Children's names being enrolled in the program:*

First and Last names

Email

example@example.com

Please fill in two phone numbers where we can reach you directly:*

Please enter a valid phone number.

What type of phone number is this?

Join our "Remind" Group Using our Code: COAHMKE to receive updates on events and closures*

Add my number for meShow me how to add myselfI'll download the app and add myselfNo thank you

Phone #2 where we can reach you directly:*

Please enter a valid phone number.

What type of phone number is this?

Anyone who cannot pickup the youth?

Primary Language*

EnglishSpanishI need an interpreterOther

Marital Status:*

SingleDivorcedMarriedWidowed

Place of Employment & Occupation:*

If Unemployed, write unemployed

Monthly Household Income*

Total number of people in your household:*

How did you hear about City on a Hill?*

Family MemberFlyerFriendOther

Guests with Disability - “Disability” with respect to an individual, means: A physical or mental impairment that substantially limits one or more of the major life activities; or a record of such an impairment; or being regarded as having such impairment.*

YesNo

If Yes, could you explain more?

Please also note which youth you are referring to.

Youth Allergies*

Food related, bees, etc.

In Case of an Emergency:

Name of an adult we should call if something happens to your child and we can't reach you:*

First NameLast Name

Emergency Phone Number*

Please enter a valid phone number.

Alternate Emergency Phone Number*

Please enter a valid phone number.

How is the emergency contact related to your child?*

My signature confirms that the above information is accurate. I understand it is my responsibility to keep the above information current.

Signature of Parent or Legal Guardian*

Date*

Date