Reading Assistance Program Form

Reading Assistance Program (RAP) Registration and Liability Waiver
List of children attending the program.
Please note any food allergies or restrictions and discuss with RAP Staff.
Child's first and last name (Child 1)

First NameLast Name
Date of Birth (Child 1)

MêsDiaAno
2 digit month, 2 digit day, 4 digit yearData
School/Grade (Child 1)
Food allergies or restrictions (Child 1)
Enter None if none. Please discuss allergies or restrictions with RAP staff.
Child's first and last name (Child 2)

First NameLast Name
Date of Birth (Child 2)

MêsDiaAno
2 digit month, 2 digit day, 4 digit yearData
School/Grade (Child 2)
Food allergies or restrictions (Child 2)
Child's first and last name (Child 3)

First NameLast Name
Date of Birth (Child 3)

MêsDiaAno
2 digit month, 2 digit day, 4 digit yearData
School/Grade (Child 3)
Food allergies or restrictions (Child 3)
Parent/guardian name

First NameLast Name
Parent/guardian address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/guardian phone number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/guardian email address
example@example.com
Emergency contact name

First NameLast Name
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
RAP Policies and Procedures
- RAP will follow the Williamsburg James City County school schedule. If they are closed, we are closed. Summer is the exception. We will have summer programming.
- Parents are required to sign their child (children) in upon arrival and out upon departure of each RAP session. Parents are welcome to wait in the building.
- Children will only be released to the person who dropped them off unless other arrangements have been made.
- You must pick your child up or assume care for them no later than 5:30 pm.
- Please stress to your children:
  - There is no running in the building
  - They must be with one of the RAP volunteers or parent at all times. (Volunteer will wait outside of restroom.)
  - Children may not leave the building without their parent. (Cannot go check the parking lot.)
  - Cell Phones must stay in pocket and not checked while in the program.
I have read and agree to the RAP policies and procedures.
In Case of Emergency:
In case of emergency, I understand every effort will be made to contact the parents or guardians of registrants. However, if parents or guardians cannot be reached, I hereby give the Williamsburg Church of Christ permission to act on my behalf, as necessary or advisable for the registrant's health, safety, and welfare. I release Williamsburg Church of Christ from liability in acting on my behalf and rendering such medical treatment and assume the financial responsibility.
I agree to the emergency permission stated above.
Waiver of Liability:
I/my child are voluntarily participating in the Reading Assistance Program (RAP), 227 Merrimac Trail, Williamsburg, VA 23185, at our own risk. I thereby waive all rights to hold the Williamsburg Church of Christ, agents and volunteers responsible for any loss, damage, or liability sustained during the Reading Assistance Program.
I have read and agree to the waiver of liability stated above.
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reviewed: January 22, 2026
Parent Signature
Printed Name

First NameLast Name
Should be Empty:

Reading Assistance Program (RAP) Registration and Liability Waiver

List of children attending the program.

RAP Policies and Procedures

In Case of Emergency:

Waiver of Liability: