Afterschool Program Registration Afterschool Program Registration What age is your child? Elementary (1st-5th) Middle (6th-8th) Both (multiple children) Elementary Camps (Grades 1-5):Freedom - serving 19802, @2401 Thatcher St (UrbanPromise headquarters)Hope - serving 19801 (Southbridge), @455 Townsend St (Mt Joy UMC)Victory - serving 19801 (Eastside), @1012 N French St (St. Joseph's Church)Promise - serving 19805, @1502 W 13th St (Westminster Pres Church)Junior High Camps (Grades 6-8):Harmony - serving 19802, @2616 Carter St (Union Baptist Church)Amen - serving 19801 & 19805, @408 E 8th St (People's Settlement)Child's Name* First Last Age*Birthday (mm/dd/yyyy)* Grade*SchoolHome Address* Street Address ZIP / Postal Code Parent Name* First Last Relationship*Parent Email Home PhoneCell PhoneWork PhoneEmergency Contact (other than parent)* First Last Phone*Medical Considerations*Second ChildChild's Name First Last AgeBirthday (mm/dd/yyyy) GradeSchoolMedical ConsiderationsThird ChildChild's Name First Last AgeBirthday (mm/dd/yyyy) GradeSchoolMedical ConsiderationsSection BreakMy child(ren) will:* walk home alone from afterschool program be picked up by Who will pick up the child:*Please read carefully, and check that you agree:* My home address meets the eligibility requirements for my chosen program location * I understand that my child will not be allowed to walk home from program unless indicated above, and will only be able to be picked up by those listed above. Any changes must be communicated to the director. * I give permission for my child to participate in the activities sponsored by UrbanPromise and other cooperating organizations in the neighborhood. * I understand the risk involved in this program and that the staff will exercise all reasonable care for my child. I will not hold UrbanPromise Ministries, Inc., or other cooperating organizations, their staff or representatives, responsible for injuries which occur to my child. * In case of a medical emergency, I understand that an effort will be made to reach me. However, I do give permission for the staff of this program to authorize emergency medical care for my child. * I understand that Christian education is part of the UrbanPromise camp program. * I understand that UrbanPromise and the cooperating organizations are not responsible for my child until and unless they arrive at the program site. * I give permission for my child’s name and photograph to be used in publications produced by UrbanPromise Ministries, Inc. * I agree to support my child and the staff of this program through accepting and enforcing the discipline structure that is used Has your child participated in camp before?*YesNoWhich one?How many years?Do you have any feedback for us?CommentsThis field is for validation purposes and should be left unchanged.