SY Registration Request

2026-2027 R.O.C.K. School Year Registration
School Year Program Hours - 2:30 - 6:00 P.M.

All forms must be completed before your child's first day at R.O.C.K. Your child's spot will not be reserved until confirmation email has been recieved. By completing these forms you have agreed to pay registration fees. Registration fees are non-refundable regardless of your drop date.

Billing Information / Changes to Schedule

We are ACH only. Contact (cmaines@zumc.org) with any questions regarding ACH/Billing.

Any changes made after the 29th of that month will not be accepted. Any days added after 29th will be charged at the unscheduled drop off rate of $30.

Any unscheduled drop-off days will not be re-billed to get the weekly discount.

We do not accept changes by email, phone, or verbal contact. Changes to your child's schedule are done by filling out a change form. Please see Kathy or Garrett if you are in need of a form.

We are a tuition based service and do not do refunds as your spot has been held and results in us refusing other families in need of child care.

Please make sure your start date and information is correct. It will be according to this date.
Child's Name*

First NameLast Name
DOB*

Grade for School Year 2026-2027*

Rows	Pre-K	K	1st	2nd	3rd	4th	5th	6th
Grade

Gender*
Child's Age*
School Attending*
Home Address*

Address

CityState / Province

Postal / Zip Code
Parent's Name (1)*

First NameLast Name
Parent's Name (2)

First NameLast Name
Parent's Business/Cell*
Format: (000) 000-0000.
Parent's Business/Cell
Format: (000) 000-0000.
Parent's E-mail*
example@example.com
Parent's Email
example@example.com
Emergency Contact*

First NameLast Name
Emergency Phone*
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Phone
Format: (000) 000-0000.
Does your child require any assistance with bathroom routines?*

YesNo
Does your child have any allergies?*

YesNo
If Yes, please specify all known allergies (food, insects, medications, etc..)
Does your child have any diagnosed behavioral, developmental, or learning conditions?*

YesNo
If yes, please specify the condition and let us know about any accommodations, interventions, or supports that are helpful for your child.
Any additional helpful information: (fears, major changes, etc...)
Persons having permission to pick my child up from ROCK (We do I.D.)*

Afternoon*

Rows	PM ROCK
Monday PM
Tuesday PM
Wednesday PM
Thursday PM
Friday PM

Your Child's Start Date :

Child's Name*

First Name
Grade*
Signature*
I desire to register my child (inserted above) going into grade (inserted above) during the 2026-2027 school year for the ROCK Program and hereby accept the agreement as follows:

Registration fees are $125 per child

After School Care

# of days Tuition due

1 $75.00

2 $150.00

3 $225.00

4 $300.00

5 $325.00

DROP OFF RATES: $30 per day

Tuition Due Date: 15th of the Month

Your registration fee is non-refundable!

Any NSF ACH payments will result in a $25 fee.

Media Consent: I understand that photographs/video may be taken at ROCK that could include my child. I give ZUMC/ROCK permission to use these photographs/videos in publications as well as advertisements. If you have any concerns please contact Kathy Gibson.

I also understand that no refund will be made for non-attendance. (See Handbook)

In signing, I am stating that I agree with the conditions of registration and can review a copy of the ROCK Handbook online at rockzumc.org/forms.html.
Parents Printed Name*

First NameLast Name
Date

MonthDayYear
Date
Spanish Classes offered

During the school year we also offer after school spanish lessons. Please inquire in the ROCK office if you would like to find out more information about these classes.

History of Immunizations
Parent Name*

First NameLast Name
By clicking Submit, you are agreeing to bring in/email a copy of your child's history of immunizations to the ROCK program for the 2025-2026 school year.

Email to: ROCK@zumc.org

Fax to Attn. of: Kathy Gibson

Your child will not be allowed to attend if all vaccinations forms are not submitted by the first day of your child's attendance

WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL ATTENTION
Child Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Emergency Phone*
Format: (000) 000-0000.
EVENT:

Date: August 4th, 2026-May 26th, 2027

Destination: Transportation from Boone Meadow, Eagle, PVE, Stonegate, Trailside, Union and ZWest

In exchange for my being allowed to participate in events sponsored by Zionsville United Methodist Church (herein referred to as "ZUMC"), I and, if I am not yet 18 years old, my parent or legal guardian (individually and collectively referred to below in the first person singular) agree to be bound by each of the following:

1. Olbigation to Inspect Facilities and Equipment. I agree that prior to participating in the event, I will inspect the facilities and equipment to be used. If I believe anything is unsafe, I will immediately advise the supervisor of the event and ZUMC of such unsafe condition(s) and refuse to participate in the event.

2. Identification of Risks. I understand the participation in the event may involve risk of serious injury, including permanent disability and death, and other losses, both to persons and property. I understand that these injuries and losses might result from the actions, inactions, negligence, or conduct of others, the rules of the event, or the condition of the premises or of any equipment used.

3. Assumption of Risk. I assume all risks, known and unknown, in any way connected with my participation in the event. I accept personal responsibility for any liability, injury, loss, or damage in any way connected with my participation in the event.

4. Waiver and Release. I waive, release, and hold harmless ZUMC and its directors, officers, sponsors, employees, volunteers, agents, successors, and assigns from all claims for any liability, injury, loss or damage in any way connected with my participation in the event, whether or not caused in whole or part by the negligence or other misconduct of ZUMC or any of the person mentioned above. I intend for this waiver and release also to apply to any relatives, personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal action or claim for such liability, injury, loss, or damage. (next page)

Furthermore, in consideration of my child's participation in the event set forth above, I hereby AGREE TO INDEMNIFY AND HOLD HARMLESS ZUMC from any and all claims, demands, rights of actions or liabilities of whatsoever nature that any person had, now has, may have or might in the future have against ZUMC, including but not limited to, any and all claims, demands, rights of actions, or liabilities based upon any NEGLIGENCE on part of ZUMC based upon, aprising out of, or in any manner connected with my child's participation in the event identified above.

5. Consent to Medical Treatment. I agree that ZUMC may provide to me, through medical personnel of its choice, customary medical or training assistance, transportation, and emergency medical services. This consent does not impose duty upon ZUMC to provide such assistance, transportation, or services.

6. Media consent. I understand that pictures of the event may include my child/children will be available for use in church publications.
I HAVE READ THIS WAIVER, RELEASE, AND CONSENT. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS WAIVER, RELEASE, AND CONSENT VOLUNTARILY.
Adult Signature(Parent or Legal Guardian)*
Parent/Legal Guardian Printed Name*

First NameLast Name
Date

MonthDayYear
Date
Medical Information
Medical Insurance Provider:*
Policy Number:*
Medical Pre-Certification Procedure(if applicable):
Special Medical Information Concerning Patient: (allergies, medications, conditions, etc.)

ROCK Child Expectations
The philosophy of the ROCK program is to ensure that each participant is provided a safe, Christian, education environment where children have structured freedom to explore, experience, and discover various aspects of physical and spiritual growth with guidance from educationally qualified, caring professionals.

The purpose of the ROCK Discipline Policy is to the ensure that each participant conducts themselves in a manner that will promote maintain an atmosphere that nurtures feelings of respect, safety, belonging, and being loved. Obtaining and maintaining desirable behavior from our participants is a shared responsibility bewteen child, parent, and ROCK staff.

The following is expected of each participant whether they are in the ROCK building, on the ROCK bus or on an offsite field trip.

Each participant is expected to:

Show respect for staff and other participants

Show respect for the Church and its facilities

Exhibit self control and an attitude of cooperation

Follow the rules and have an attitude of obedience

Be encouring towards others

Each participant is expected not to:

Use inappropriate language, disrespectful language, or "put downs"

Bully other children in any way

The ROCK staff will maintain communication with the parents of children who are struggling with any behavorial issues according to the ROCK Parent Handbook.

Each parent will receive a ROCk Parent Handbook upon completion of registration. In signing I am stating that I will review, sign, and return signed copy of handbook to the ROCK Program.
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Parent's Notice

State form 49444 (R/1-09) / BCC 0035
I understand that this day care ministry is not licensed under the laws of Indiana. However, I understand that this day care ministry complies with the State rules concerning sanitation and fire safety for the primary use of the structure in which it is conducted. I understand that it is my responsibility to ensure that the nutritional and health needs of my child are met while my child is at the day care ministry.
Signature of Parent or Guardian*
Name of Child Enrolled*

First NameLast Name
This notice does not absolve a day care ministry from liability for injury to a child while the child is at the day care ministry if the cause of the injury is negligence or intentional wrongdoing on the part of the day care ministry or an employee of the day care ministry.
The facility name is, "R.O.C.K."

Address is, 9644 Whitestown Rd, Zionsville, IN 46077
Name of Facility*
Address of Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ROCK MEDICATION PERMISSION
Child's Name*

First NameLast Name
Age*
A few children experience an allergic reaction to the sting of bees, wasps, hornets, and/or food. Since allergic reactions can be serious at times require prompt treatment, our medical consultant has recommened that staff administer oral Diphenhydramine HCL/Benadryl to children who have been stung or are exhibiting a reaction to food, dye, or juice.
THE R.O.C.K. program is hereby given permission to administer the medication Diphenhydramine HCL/Benadryl by mouth to my child named above, according the dosage outlined below, in the event that my child is stung by a bee or wasp at camp or exhibits a reaction to food.*

YesNo
PARENTS MUST FILL IN DOSAGE AMOUNT OR WE CANNOT ADMINISTER THE MEDICATION

**If parent does not put a dosage, we cannot administer the medication.
Type a questionDOSAGE: (CHECK ONE) /Children 6 to 11 years of age / If other.. DOSAGE FOR CHILDREN UNDER 6 YEARS OF AGE: 1/2 tsp per 10 pounds (DO NOT EXCEED 2 tsp*

1 teaspoonful(12.5mg)2 teaspoonfuls(25mg)Other
My child has had a severe life-threatening reaction to a bee or wasp sting.*

YesNo
If Yes, my child has had a severe life-threatening reaction to a bee or wasp sting. Please explain the type and symptoms of this reaction and what needs to be done.
Signature*
Printed Name:*
Emergency Phone Number*
Format: (000) 000-0000.

ROCK Parent Handbook and Financial Aid Policy
ROCK School Year Homepage

Rock Parent Handbook

ROCK Financial Aid Policy

By signing below I have agreed to the terms and conditions along with procedures and guidlines of the ROCK program.
Signature*
Printed Name:*

ACH Form
Use bank account currently on file?*

YesNo
Financial Institution Name:*
Name on Account:*
Type of Account:*

CheckingSavings
Financial Institution Account Number*
Financial Institution Routing Number (ABA)*
Signature*
Printed Name:*
Should be Empty:

2026-2027 R.O.C.K. School Year Registration

History of Immunizations

WAIVER, RELEASE OF LIABILITY, AND CONSENT TO MEDICAL ATTENTION

Medical Information

ROCK Child Expectations

Parent's Notice

ROCK MEDICATION PERMISSION

ROCK Parent Handbook and Financial Aid Policy

ACH Form