JMCC Spring 2023 After School Attendee Registration Form

Tutoring and Extracurricular Request Form
Description of Service Opportunities

We offer many different after-school activities at Jacob's Mission Community Center. Each child is welcome to participate in one (1) Tutoring session and one (1) Extracurricular Activity. Please note that tutoring sessions are typically provided twice per week. If the child cannot attend twice per week, they may select the date that works best for them.

Fill Out Detailed Request For for EACH Child in Foster Care, Aged Out Youth, Foster/Adopted Child or Biological Child from foster/adopt household that will be attending our after-school program in order of youngest to oldest based on grade level (K-12).
Child #1 Given Legal Name: **

First NameLast Name
Age:*
Birth Month (we like to celebrate them)*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Full Birthdate (example: 04-23-07)*
Grade*

K123456789101112
Does Child or Youth have an IEP?*

YesNo
Does Child or Youth have a Behavioral Health Diagnosis*

YesNo
Behavioral Health Diagnosis*
Does Child or Youth have a Medical Health Diagnosis*

YesNo
Medical Health Diagnosis*
Does Child or Youth have any Rescue Medication? (example: EpiPen, Inhaler, Glucagon)*

YesNo
Rescue Medication Used for which Diagnosis? *
Name of Medication and Strength *
Ethnicity*

WhiteHispanicBlackAsian Pacific IslanderAmerican Indian/Alaskan WhiteMulti EthnicUnknown
Insurance Name:*
CMDP, AHCCS ID or Member ID NUMBER (this information will only be used if there is an emergency)*
Does this Child or Youth have Child Welfare Involvement) are they a Child or Youth in Foster Care?)*

YesNo
Upload Photo or File of Notice To Provider (NTP), Tribal or DCS Guardianship Paperwork for Foster Children in your Care OR Upload State-Issued Driver's License/ID Card for Aged Out Youth

Browse Files

Cancelof
Are you interested in Tutoring for this child?*

Yes - FULLNo
Tutoring - Tuesday only*

FULLFULLFULLNot Interested
Tutoring - Wednesday only*

FULLFULLNot Interested
Are you interested in Extra Curricular Activities?*

Yes - SELECT ONLY ONENo
Cooking Class (K-6th grade) Tuesday*

4pm (k-6th)Not Interested
Music Class Tuesday

4 - 45pmNot Interested
Cooking Class (7-12th grade) Tuesday*

5pmNot Interested
Dungeons and Dragons Tuesday*

5-5:45 pmNot Interested
Keyboard (beginner) Tuesday - please note class is capped at 5 students*

5-5:45 pmNot Interested
Keyboard (advanced) Tuesday - please note class is capped at 5 students*

6-6:45 pmNot Interested
Sewing - Tuesday

6-6:45 pmNot Interested
Musical Theater Wednesdays*

4-4:45 pmNot Interested
Arts & Crafts - wednesday*

5-5-45 pmNot Interested
Guitar- Wednesday*

5pmNot Interested
Legos - Wednesday*

5pmNot Interested
Guitar - Wednesday- For kids in Group home*

6-6:45 pmNot Interested
Dance - Wednesday*

6-6:45 pmNot Interested
Do you have Additional Children to Sign Up?*

YesNo

Liability Release Form
Name of Guardian and/or "Minor's" Authorized Representative *

First NameLast Name
PARTICIPANT AGREEMENT, RELEASE, WAIVER, AND ASSUMPTION OF RISK - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19 - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
GRANT OF RIGHT TO USE LIKENESS - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
I acknowledge that I have read the above waiver and release, understand that I have given up substantial rights by signing it, and sign it voluntarily.*

I agree
Signature*

Clear
Dated

MonthDayYear
Date
I have read this entire Release Form and fully understand its contents. I am signing it voluntarily, without any duress or undue influence.*

I agree
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JMCC Spring 2023 After School Tutoring and classes.

Emergency Contact

Household Demographics

Tutoring and Extracurricular Request Form

Liability Release Form