GSCS Family Registration Form Revised

Good Samaritan Community Services

FAMILY HOUSEHOLD REGISTRATION FORM
Date *

Month Day Year
Date
HEAD OF HOUSEHOLD/ADULT PARTICIPANT

Please provide information on the primary caregiver or adult applying for services.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Address *

Street Address

Street Address Line 2

City State

Zip Code
*If San Antonio, list City Council District:
Email
example@example.com
Home Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Marital Status *
Disability Status *
Race *
Hispanic Origin *
Employment *
Employer and Title
How did you hear about our services? *
HOUSEHOLD DEMOGRAPHIC INFORMATION
Living Situation (check all that apply) *

Two Parent (Married) Two Parent (Unmarried) Single Parent Home Legal Guardian Teen Parent Grandparent Caregiver Forster Parent Adopted Child Multi-generational Living in Public Housing Homeless Living in Shelter Live with parents/family Temporary living arrangement Renting Home Own Home
Number of family members in household (other than yourself) *
Preferred Language in Household *
Highest Grade Completed by Primary Caregiver *
Highest Grade Completed by Secondary Caregiver
Health Insurance for Household Members *
Military Status *
Annual Household Income *
Sources of Household Income (check all that reply) *

Not Working Income from Work Retirement/Pension TANF SNAP Unemployment Worker's Comp. Social Security/SSI Alimony Child Support VA Benefits Rent from Tenants Cash assistance from family/others
Has your family experienced any of the following during the past two years? (check all that apply)

Illness Death of family member Separation/divorce from spouse or partner Personal trauma/injury Loss of home Loss of employment Physical abuse Sexual abuse Prison
Have any of the following behaviors presented concerns for your family? (check all that apply)

Relationship problems Struggles with parenting Conflict in household Controlling temper Gambling Use of alcohol Use of drugs Stress Traumatic event School Problems Eating Disorder Depression/Mental Health Physical Disability Developmental Delay Behavior Concern Child Welfare Involvement
Does anyone in your family abuse alcohol or drugs? (check all that apply.)

Primary Caregiver Spouse/partner Child in household
OTHER HOUSEHOLD MEMBERS

List all individuals, other than yourself, who live in your household.
Household Member 1 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 2 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 3 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
Phone Number

Area Code Phone Number
School Name
District
Grade
Student ID
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 4 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
Phone Number

Area Code Phone Number
School Name
District
Grade
Student ID
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 5 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 6 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 7 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
Household Member 8 *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to Head of Household: *
Marital Status
Race *
Hispanic Origin *
Gender *
Disability Status *
School Name
District
Grade
Student ID
Phone Number

Area Code Phone Number
Are you enrolling this household member in GSCS services? *

Yes No
PROGRAM ENROLLMENT FORM

(*Indicates Required Field)
Participant Name (Household Member 1) *

First Name Last Name
DOB *

Month Day Year
Date
Participant Name (Household Member 2) *

First Name Last Name
DOB *

Month Day Year
Date
Participant Name (Household Member 3) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Participant Name (Household Member 4) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Participant Name (Household Member 5) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Participant Name (Household Member 6) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Participant Name (Household Member 7) *

First Name Last Name
Date of Birth *

Month Day Year
Date
Participant Name (Household Member 8) *

First Name Last Name
Date of Birth *

Month Day Year
Date
EMERGENCY CONTACTS

The following individuals may be contacted in the case of an emergency.
Emergency Contact #1 *

First Name Last Name
Relationship to Participant *
Address *
Phone Number *

Area Code Phone Number
Emergency Contact #2

First Name Last Name
Relationship to Participant
Address
Phone Number

Area Code Phone Number
Emergency Contact #3

First Name Last Name
Relationship to Participant
Address
Phone Number

Area Code Phone Number
Emergency Contact # 4

First Name Last Name
Relationship to Participant
Address
Phone Number

Area Code Phone Number
COMMUNICATION *
Good Samaritan Community Services (GSCS) utilizes an electronic communication tool, to share important program updates and reminders with families. This tool is used to remind participants and their families of important events such as program closures, parent meetings, scheduled conferences and home visits, and other program activities.
Initials *

Clear
Permission to Participate in Water Activities *
I give permission for my child to participate in water activities such as water play and swimming activities. I understand that I will receive prior notification of these events, and these activities will be guided by adult/staff supervision.
Permission to Walk Home *
I give permission for my child (ren) to walk home.
Participation Agreement *
Permission is given for the participant listed above to participate in Good Samaritan Community Services’ programs, planned assessments and activities. I understand that notification of special events and their requirements will be provided in advance. I also understand that not all participants may be chosen to participate in all special events. I also acknowledge that the participant listed above is fully able to participate in program activities and can function in a group environment.
Acknowledgement of Service Termination *
I understand that failure to follow program guidelines may result in service termination.
Permission to Transport *
I give permission for the participant listed above to be transported off-site by GSCS staff for the following purposes: 1) To participate in off-site activities including field trips; 2)To evacuate the campus due to weather or other emergency situations; and 3) To obtain emergency medical treatment.
Permission to Release Personal Data *
I understand the data collected will be used for program evaluation purposes. I give permission for the records of the participant listed above to be shared for lawful reasons with other governmental or social services agencies. I understand that personal information will be held confidential and will not be released to anyone without my written authorization to do so.
Permission for Photography & Videotaping *
I give permission for the participant listed above to be photographed or videotaped and for these photos, videos and personal success stories to be used in public media (TV, radio, newspaper, online media and other publications) to help inform the public about GSCS services
ORIENTATION TO PROGRAM SERVICES

I acknowledge I have been oriented to program services, either in person or through written communication (letter explaining program services and expectations and/or received a copy of the program handbook), that included program hours and days of operation, program procedures and participant expectations.
Initials *

Clear
RELEASE OF LIABILITY

I hereby release Good Samaritan Community Services Staff and affiliates from all liabilities that may arise from accidental injury or damage to my or my child’s personal property. This includes, but is not limited to, all claims involving transportation to or from any activities and against any person or organization providing activities.
Initials *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Signature

Clear
Should be Empty:

Good Samaritan Community Services

HEAD OF HOUSEHOLD/ADULT PARTICIPANT

HOUSEHOLD DEMOGRAPHIC INFORMATION

OTHER HOUSEHOLD MEMBERS

PROGRAM ENROLLMENT FORM

EMERGENCY CONTACTS

ORIENTATION TO PROGRAM SERVICES

RELEASE OF LIABILITY