The HUB Registration Form

Please do not hesitate to call, text, or email if you have any questions or concerns!

Call or text 419-731-3249 or email info@wyandotconnections.org.

HUB Kids is open to all 4th - 9th grades.

Child Name*

First NameLast Name

Child's Nickname*

Date of Birth*

Date

Grade*

Child's Phone (optional)

Please enter a valid phone number.

Parent/Legal Guardian Name*

First NameLast Name

Relationship to Child*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Prefer?*

CallText

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Relationship to Child*

Emergency Contact Phone*

Please enter a valid phone number.

Who is NOT permitted to pick up your child from The HUB? Please list name and any details we need to be made aware of.

Do you want to be contacted if anyone who is NOT listed comes to pick up your child?

YesNo

Sign-in and Sign-out

Your child will be required to sign in when entering The HUB and sign out when leaving.

Once your child leaves The HUB he/she will not be able to return that same day.

Wyandot Community Connections/The HUB is not responsible if your child leaves the facility before the time agreed upon between you and your child. If there is an issue we will help in any way we can.

Illness

Please do not send your child to The HUB if he/she is ill. If your child does not attend school due to illness they may not come to The HUB. They are welcome back when symptom free for 24 hours. If your child becomes ill while attending The HUB you will receive a call to pick up your child.

Please list any medical, allergies, or other issues that the WCC staff should be aware of:*

I (parent/legal guardian) reviewed the Parent/Youth Handbook (download the handbook at wyandotconnections.org) with my child (named above). By signing below, we (parent and child) understand and agree to abide by the rules and regulations of Wyandot Community Connections (“WCC”).*

Yes

I (parent/legal guardian) give permission and consent to Wyandot Community Connections and third parties collaborating with WCC to make, reproduce, edit, broadcast, or rebroadcast any photo, video, soundtrack recording of my child (named above) while participating in WCC activities and/or programs, and including any written or spoken narrative account of experiences at the Center for publication, display, or exhibition in promotions, advertising, and legitimate business uses by and for WCC. I further understand there will be no compensation to, and/or claim, by me or my child for such items.*

YesNo

I (parent/legal guardian) agree and affirm as follows: in consideration for my child, as named here, participating in WCC programs and activities, I agree to assume the risk of such activities and further hold harmless WCC, employees, and volunteers from any and all claims, suits, losses, or related causes of action for damages, including but not limited to, such claims that may result from m/our injury or death, accidental or otherwise, during or arising in any way from my/our WCC involvement. I further represent and affirm that I have the legal capacity to bind any minor and or the heirs and or estate of same for whom this consent is given.*

Yes

In the event that I cannot be reached in an emergency, I hereby give permission to medical personnel to order x-rays, routine tests, and treatment for my child if he or she becomes ill. I hereby give permission to the physician to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child as named here. I hereby give permission for my child to participate in screenings and testings, which may identify additional services which may benefit my child. I further agree to be financially responsible for all such medical services.*

YesNo

The information I have provided is current and correct to the best of my knowledge. I will let WCC know of any change in the information I have provided.*

Yes

Child Signature

Parent/Legal Guardian Signature