FUMC After School Registration

First UMC After School Program Registration
We have limited availability. After reaching maximum capacity, you will be added to our wait list and contacted when openings become available.
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Grade Attending in 2025-26*
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Care #*
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home

Area CodePhone Number
Cell*

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Infomation
Is there anything we should know about your child to help us work with them (learning preferences, etc.)
What are some of your child's interests? (Favorite games, sports, etc.)
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed here? Tylenol/Acetaminophen, Advil/Motrin/ibuprofen, Antacid, Benadryl, Hydrocortisone, Neosporin/Triple Antibiotic Cream

YesNo
Please provide your health insurance company.*
Policy Number*
Group Number*
Please list the people authorized to pick up your child.
Activity Permission - I do hereby certify that my child has permission to participate in all activities from August 1, 2025 through August 31, 2026. Any permissions granted by this form includes Safe-Sanctuary approved transportation.*

YesNo
In House Photo Permission - I do hereby give FUMC Hershey permission to use my child's photograph in newsletters and slideshows distributed or shown to the congregation at a FUMC Hershey event.*

YesNo
Website and Social Media Permission - I do hereby give FUMC Hershey permission to use my child's photograph on the church website, Facebook page, or Instagram account (understanding that his/her name will not be used).*

YesNo
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell*

Area CodePhone Number
Terms and Conditions of Agreement -We (I) the parent(s) or legal guardian(s) of this student hereby grant our (my) permission for him/her to participate fully in the events and activities sponsored by or attended by First United Methodist Church of Hershey during the time period of August 1, 2025 through August 31, 2026. Authorization and permission is hereby given to said church (FUMC Hershey) to furnish any necessary transportation, food, lodging, for this participant during the excursions and activities of the children's ministry program. I understand all safety precautions will be taken at all times by First United Methodist Church and its agents during all events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold First United Methodist Church, its leaders, employees, and/or volunteer staff liable for damages, losses, disease, or injuries incurred by the participant who is the subject of this form. Furthermore, I, on behalf of my child, hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. I understand that in the event medical or dental intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached or the alternate contact person cannot be reached in an emergency, I hereby give my permission to a licensed Physician or Dentist at an office or hospital selected by the activity leader to hospitalize, to secure medical treatment and/or to order an examination, injection, x-ray, anesthesia, or surgery for my child as deemed necessary. I understand that First United Methodist Church does not carry accident or medical insurance on participating volunteers. I agree that my insurance company will be used for such medical care expenses. I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance coverage and that I am responsible for the payment of any medical bills.*

YesNo
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
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First UMC After School Program Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian