Littig House Registration Fall 2024/25

Littig House Community Center

Online Registration Form - 2023-2024
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. An e-mail receipt does not confirm your child is enrolled in the program.

Todos los registros se reciben y revisan por orden de llegada. Al llenar todos los espacios abiertos, todos los envíos adicionales se agregarán a nuestra lista de espera. Un recibo por correo electrónico no confirma que su hijo esté inscrito en el programa.
Participant Information
First Name*
Last Name*
Age
Birth Date*

MonthDayYear
Gender*

FM
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Full Name*

First NameLast Name
Home Phone*
Cell
Work
E-mail
example@example.com
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 Address (If not the same as your child)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Programs & Services

Please check off the program(s) the participant is interested in enrolling in.
Education Services

JumpStart Academic (School Year)Pre-Teen & Teen Tutoring
Family Life & Youth Development

Youth CouncilSeniors Support
Social Supports

Education AdvocacyHousing AdvocacyMediation
Academic Information
Grade Attending
School Attending
Littig House will conduct quarterly evaluations on core subject areas to understand your child's growth and areas of improvement. With consent, Litig House will can receive documents from the local school district concerning academic and social/emotional support.
Consent

I give consent for Littig House to receive access to academic records.I do not give consent for Littig House to receive access to academic records.
Please note for enrollment, we require all parents to provide quarterly progress reports and report cards to help us measure your child's success and in creating an academic support plan.
Sign Out Information

Safety is a top priority in the program. Therefore, no child enrolled in the program will be released from the program without: (a) parent/guardian signature or (b) the signature from one of the two individuals listed as an emergency contact. You may add one (1) additional person to pick up your child other than the three contacts on the form. Photo ID is required, if picked up from anyone other than the parent/guardian of child.
Please check the appropriate box that indicates your child's mode of transportation.*

My child will walk home daily.My child will be picked up.Other
Please list your additional one person authorized to pick up your child.
Emergency Contact #1

Littig House requires two emergency contacts for your child to be enrolled in the program.
Full Name (E1)*

First NameLast Name
Phone Number (E1)*
Relation (E1)*
Emergency Contact #2

Littig House requires two emergency contacts for your child to be enrolled in the program.
Full Name (E2)*

First NameLast Name
Phone Number (E2)*
Relation (E2)*
Medical Information
Does your child have any allergies?*

YesNo
If yes please list, including any allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Does your child have any food or dietary restrictions? If yes, please list the restrictions.
Doctors Name*

First NameLast Name
Doctors Phone Number*
Work
Photo Release

We often take pictures during activities to share with youth and families. We also may use specific photographs for promotional purposes only. I agree Littig House to use photos for the enrolled participant for educational and promotional purposes.
I give Littig House permission to use photographs of the participant.

YesNo
I understand that all registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, I understand all additional submissions will be added to our waiting list. I understand that an e-mail receipt of your application does not guarantee a slot. I understand it is required to provide a copy of your child's last progress report or report card as part of the enrollment process. I attest that any and all information provided on this form is accurate and true.
Should be Empty:

Littig House Community Center

Participant Information

Parent/Guardian Information

Programs & Services

Academic Information

Sign Out Information

Emergency Contact #1

Emergency Contact #2

Medical Information

Photo Release