Registration Form
Virtual Learning Hub
Space is limited and available only on a first come first served basis.
Child Information
*
Grade
First Name
Last Name
School
*
RB Hudson STEAM Academy
School of Discovery
Clark Elementary
Edgewood Elementary
Knox Elementary
Meadowview Elementary
Payne Elementary
Sophia P. Kingston Elementary
Parent Information
*
Prefix
First Name
Last Name
Place of Employment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Home Phone
*
-
Area Code
Phone Number
Work Phone
*
-
Area Code
Phone Number
E-mail
*
Acknowledgements, Releases, and Waivers
Each section must be fully completed to enroll
Acknowledgement of Enrollment Process
*
I understand that submitting an application does not guarantee my child(ren) will be allowed to participate in the program.
I understand that if accepted, I may have to provide verification of my employment status and scheduled work times.
I understand that my child(ren) must abide by all rules of the Gospel Tabernacle Church as well as Selma City Schools Virtual Program.
I understand that my child(ren) must bring their own device and equipment and my child (ren) is responsible for their device(s) and equipment and completing all schoolwork. Gospel Tabernacle Church does not accept liability for any damaged equipment or incomplete work.
I understand that my child(ren) must adhere to Gospel Tabernacle Church, Selma City Schools and CDC Protocols (Daily temperature checks, screenings, mask wearing, soap and sanitizer usage as well as social distancing).
Signature
*
Release & Waivers
*
I hereby release Gospel Tabernacle Church and any of it’s entities, volunteers, and employees from any liability concerning the health and well being of my child while attending the Virtual Learning Hub Program.
I hereby state that my child has not been around any person with the Coronavirus, nor has my child showed any of the symptoms according to the CDC guidelines.
I hereby state that my child has not been out of the country in the last 9 months and does not have a temperature of over 98.0.
I hereby give permission for Gospel Tabernacle Church volunteers and employers permission to contact medical personnel on behalf of my child while attending the Virtual Learning Hub Program.
I hereby give permission for my child to be photographed during the Virtual Learning Hub for advertising purpose.
Signature
*
Acknowledgment of Rules
*
Parents are not allowed inside the church. Your child will be dropped off and signed out at the door each day.
Your child will not be allowed to share equipment
Your child’s temperature will be taken at the door each morning and possibly throughout the day.
Your child can ONLY be signed out and released to authorized person(s) listed below. The authorized person MUST have picture identification when signing out and picking up.
Authorized Person(s)
*
Signature
*
Submit Form
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