Empower After School Registration

The Salvation Army

Winnebago County
EMPOWER AFTER SCHOOL REGISTRATION
Registration Fee: $25 per student; $50 total for 2 or more students per household

Please bring cash or checks made payable to The Salvation Army of Winnebago County P.O. Box 4159 Rockford, IL 61110
2023-2024 School Year

Location: The Salvation Army Tabernacle Corps
REGISTRATION DATE

MonthDayYear
Date
Child Information
CHILD NAME:
NEW MEMBER? YES/NO
ADDRESS
CITY
STATE
ZIP
SEX M/F
Age
BIRTHDATE

MonthDayYear
Date
GRADE
SCHOOL
Student ID Number
Emergency/Medical Information
NAME
RELATIONSHIP
TELEPHONE NUMBER
ALTERNATE NUMBER
NAME
RELATIONSHIP
TELEPHONE NUMBER
ALTERNATE NUMBER
ALLERGIES
DIETARY RESTRICTIONS
IS YOUR CHILD ON ANY MEDICATION THAT WE WOULD NEED TO BE AWARE OF?
Yes or No

YesNo
Type?
Health Insurance Information
I have health insurance

YesNo
Insurance Company
Policy Number
Phone Number
Medical Doctor
CHILD TRANSPORTATION/PICK UP INFORMATION

The following people have my permission to pick up my child from the Salvation Army After School Program (List all possible):
NAME
RELATIONSHIP
PHONE NUMBER
NAME
RELATIONSHIP
PHONE NUMBER
NAME
RELATIONSHIP
PHONE NUMBER
The Salvation Army Winnebago County - After School Program Permission / Waiver Form 2023
#1 Parent/Guardian
Street
City
State
Zip
Phone Number
Please enter a valid phone number.
Email
example@example.com
#2 Parent/Guardian
Street
City
State
Zip
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please initial in the space provided

Functions and Activities It is my understanding that participating in the programs and recreational and other activities of The Salvation Army is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related a accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
Functions and Activities
Release of Liability By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child in the activities, whether such risks are known or unknown to me at this time. I further release The Salvation Army and its staff, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against The Salvation Army or its staff, volunteers, or agents.
I further agree to indemnify and hold harmless The Salvation Army and its staff volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.
Release of Liability
First Aid and Emergency Medical Treatment I recognize that there may be occasions where the child named above or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of The Salvation Army to seek and secure any needed medical attention or treatment for the child named above or me, if I am a participant, including hospitalization if in the agent's opinion such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again; I agree to pay for the medical treatment.
First Aid and Emergency Medical Treatment
Publicity On occasion, The Salvation Army takes photographs or makes an audio or videotape recording of children and/or adults involved in unit activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in The Salvation Army publications or advertising materials tolet others know about our ministry. In addition, local news organizations may hear of our activities or events; and The Salvation Army may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above or me, if I am participating, to be used, distributed, or displayed as agents of the Salvation Army see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media or for such photographs and other audio or visual records to be used by the news media.
Publicity
Other information leaders should know about the child
For Use Only if the Participant is a Minor I represent that I am the parent/guardian of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of The Salvation Army, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of The Salvation Army, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
Print Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian

Clear
Date

MonthDayYear
Date

The Salvation Army

EMPOWER AFTER SCHOOL REGISTRATION

Registration Fee: $25 per student; $50 total for 2 or more students per household

Child Information

Emergency/Medical Information

Health Insurance Information

CHILD TRANSPORTATION/PICK UP INFORMATION

The Salvation Army Winnebago County - After School Program Permission / Waiver Form 2023

To Complete Registration Review Parent Handbook

Parent and Child Agreement