Virtual Learning Registration

Registration Form
Virtual Learning Hub

Space is limited and available only on a first come first served basis.
Child Information*

GradeFirst NameLast Name
School*
Parent Information*

PrefixFirst NameLast Name
Place of Employment*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Work Phone*

Area CodePhone Number
E-mail*
Acknowledgements, Releases, and Waivers

Each section must be fully completed to enroll
Acknowledgement of Enrollment Process*

I understand that submitting an application does not guarantee my child(ren) will be allowed to participate in the program.I understand that if accepted, I may have to provide verification of my employment status and scheduled work times.I understand that my child(ren) must abide by all rules of the Gospel Tabernacle Church as well as Selma City Schools Virtual Program.I understand that my child(ren) must bring their own device and equipment and my child (ren) is responsible for their device(s) and equipment and completing all schoolwork. Gospel Tabernacle Church does not accept liability for any damaged equipment or incomplete work.I understand that my child(ren) must adhere to Gospel Tabernacle Church, Selma City Schools and CDC Protocols (Daily temperature checks, screenings, mask wearing, soap and sanitizer usage as well as social distancing).
Signature*

Clear
Release & Waivers*

I hereby release Gospel Tabernacle Church and any of it’s entities, volunteers, and employees from any liability concerning the health and well being of my child while attending the Virtual Learning Hub Program.I hereby state that my child has not been around any person with the Coronavirus, nor has my child showed any of the symptoms according to the CDC guidelines.I hereby state that my child has not been out of the country in the last 9 months and does not have a temperature of over 98.0.I hereby give permission for Gospel Tabernacle Church volunteers and employers permission to contact medical personnel on behalf of my child while attending the Virtual Learning Hub Program.I hereby give permission for my child to be photographed during the Virtual Learning Hub for advertising purpose.
Signature*

Clear
Acknowledgment of Rules*

Parents are not allowed inside the church. Your child will be dropped off and signed out at the door each day.Your child will not be allowed to share equipmentYour child’s temperature will be taken at the door each morning and possibly throughout the day.Your child can ONLY be signed out and released to authorized person(s) listed below. The authorized person MUST have picture identification when signing out and picking up.
Authorized Person(s)*
Signature*

Clear
Should be Empty:

Virtual Learning Hub

Acknowledgements, Releases, and Waivers