VILLAGER PNO APPLICATION

Villager's Name

Gender

School name

Grade

Date

Age

Primary/Secondary Diagnosis

Medical Conditions (Allergies, Seizures, Asthma, Etc).

Further Information (Warning Signs/Duration)

Doctor Name

Doctor Phone Number

Area CodePhone Number

Father's Name

Mother's Name

Address

City

Zip

Phone

Area CodePhone Number

Phone

Area CodePhone Number

Cell #

Email

example@example.com

Email

example@example.com

PRIMARY Contact Name and Number for Villager

EMERGENCY CONTACTS & AUTHORIZED PERSONS FOR PICK UP (must be someone other parent or guardian)

Name

Relationship

Phone

Area CodePhone Number

Name

Relationship

Phone

Area CodePhone Number

Does this individual have special needs (developmental, physical, emotional) that require accommodations?NoYes (If yes, please book an appointment by calling 678-355-8338)

How did you hear about us ?

What do you hope to gain from the Parents Night Out program?

What areas or goals would you like the villager to improve on?

In case of an emergency Up Giving Village (UGV) staff and volunteers may authorize the physician of choice to provide emergency care if parent/guardian cannot be contacted immediately.

INITIAL

I do hereby release and hold harmless UGV and its duly appointed employees and volunteers from all claims and damages due to personal injury to the villager.

INITIAL

UGV will notify me, should my villager become ill or uncontrollable and I will be responsible for picking up my villager immediately upon notification.

INITIAL

I understand that a participant may not be accepted into or may be removed from Up Giving Village programs if their presence compromises the health, safety, well-being, or enjoyment of themselves or others.

The Villagers' Profile must be completed for all individuals requiring additional accommodations to ensure proper support. This form must be submitted at least 3 days before the program begins to allow us to adjust staff-to-participant ratios and other program elements as necessary. Please note that we are unable to provide one-on-one assistance.

Villagers Profile page link

INITIAL

UGV has permission to take photographic images and videos of my villager while in attendance at the facility &functions. Images will be used for publicity purposes.

INITIAL

I give permission for my villager’s school teacher/instructor to release information to UGV concerning behavior management plans and all other information that may be related to providing a positive experience while attending the program.

INITIAL

I realize I am responsible for picking-up my villager or having an authorized person on the list to pick- up my villager after each session. I realize the Family Handbok outlines the pick-up policy that includes signing-out procedures, and being on time. If I am not on time, I realize there will be a late fee DUE.

INITIAL

I understand that a $40 donation is due before my villager can attend any specified Parents Night Out events.

Outside financial assistance must have proper documentation on file and approved with Up Giving Village before the villager can attend any Parents' Night Out session(s).

Payment Link

INITIAL

For your participation, please review, sign, and submit the Up Giving Village Liability Wavier Form. In accordance with the Up Giving Village Liability Waiver, I acknowledge and accept the terms by providing my initals.

INITIAL

I recognize that UGV will follow all CDC Guidelines for Covid-19. This may include, but are not limited to: quarantine when necessary, wearing masks, and maintaining appropriate social distancing.

I agree to send my villager(s) with appropriate face covering when necessary and that they will be encouraged to wear them when unable to be socially distant from other villagers.

INITIAL

To ensure you're familiar with our policies and procedures, please take some time to review the Up Giving Village Family Handbook.

To ensure everyone is aware of our expectations, please confirm with your initals that you have read and agree to the policies and procedures outlined in the Up Giving Village Family Handbook.

If I have any questions, I realize I can reach Up Giving Village either by phone at (678) 355-8338 or via email at WeCare@UpGivingVillage.com

INITIAL

Villager's Name

Date

Parent Completing Form

Signature

Villager Autobiography

Please place Villagers Photo Here

Hi, my name is

I am allergic to

My favorite hobbies/recreational activities are

My least favorite activities are

My favorite snacks are

My least favorite snacks are

I become frustrated/angry when

When I am frustrated/angry, help me by

I am happy when

Other things you should know about me are

Photo of Villager

Up Giving Village

6167 Prestley Mill Rd

Douglasville, GA, 30134

678.355.8338

Parents' Night Out Registration Form

Up Giving Village is committed to inclusion where children of all abilities are able to participate meaningfully in all aspects of Up Giving Village programs.

Please complete the entire form to be registered

VILLAGER APPLICATION

FAMILY INFORMATION

PNO PARENTAL AGREEMENT