After School Program Application Form
25-26
Student Information
Name
*
First Name
Last Name
Grade
*
School Last Attended
*
Gender
Please Select
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your student currently receive services through an Individualized Education Program (IEP) or a 504 Plan at school? This information is optional and helps us better support your child during tutoring or program activities. Information shared in this form will only be used to support your student’s learning and will remain confidential.
Yes, an IEP
Yes, a 504 Plan
No
Prefer not to answer
If your student receives services or accommodations at school, are there any strategies or supports that help them learn best that you would like us to be aware of? (Optional)
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Emergency Information
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Format: (000) 000-0000.
Health Information
Family Doctor
First Name
Last Name
Clinic
Phone Number
Format: (000) 000-0000.
Please let us know if this child has any allergies
*
List medications this child is currently taking
Can this child take part in regular physical activities?
*
Yes
No
Please indicate any related information/ the desired area of focus for tutoring.
After School Program Schedule
October 31st to April 30th | Please schedule time slots in the app!
Terms and Conditions
I, the parent or guardian of the minor participant, will hold harmless Harvest of Gold, Bible Missionary Baptist Church, CCYC, Wilmington City Schools, Wilmington College volunteer student tutors, and the servants, agents, employees, trustees, directors, representatives, and volunteers from any and all injuries, damages, claims, costs, expenses, losses, attorneys fees, and/or every loss of whatsoever nature that I and/or the minor participant incurs or may incur arising out of my and or the minor participant's participation in an event or activity sponsored or supervised, and/or approved as part of the Harvest of Gold/WCS/Wilmington College Partnership official and unofficial programs. I am solely responsible for payment of all costs resulting from the rendering of medical aid and ambulance services to myself and/or the minor participant in any event and/or activity of the Harvest of Gold/WCS/Wilmington College After School Program. Neither Bible Missionary Baptist Church nor Harvest of Gold nor Wilmington City Schools nor Wilmington College carries any medical and/or liability insurance to cover participants. Participation in all activities is voluntary. This release of liability, assumption of risk, and medical authorization shall be binding upon me and/or the minor participant, my/our heirs, administrators, executors, personal representatives, and assigns. I have read the above release of liability, assumption of risk, and medical authorization and understand the provisions thereof and I and/or the minor participant am/is voluntarily participating in the Harvest of Gold/WCS/ Wilmington College Partnership After School program subject to the terms and conditions thereof. Select yes if you have read and agreed to the terms.
*
Please Select
yes
no
By signing this form, I also give Harvest of Gold of Wilmington, Inc. permission to use pictures taken of my son/daughter. The pictures could be used on social media, flyers, brochures, or newsletters for advertisement and grant writing.
*
Date
*
-
Month
-
Day
Year
Date
Should be Empty: