After School Program Registration

Step 1 - Register

1st Child's Name *
1st Child's Name
Birthdate *
Birthdate
Gender *
IF SIGNING UP MORE THAN ONE PERSON, PLEASE FILL OUT INFORMATION BELOW: (NAME, GENDER, BIRTHDATE)
Second Child's Name
Second Child's Name
Birthdate
Birthdate
Gender
PARENT OR GUARDIAN INFORMATION
Primary Contact Name *
Primary Contact Name
Home Address *
Home Address
Emergency contact phone *
Emergency contact phone
List names and phone number of people who you authorize to pickup your child (other than you)
EMERGENCY MEDICAL INFORMATION
PERMISSION IS GIVEN TO ONE WITH HEART FOR THE FOLLOWING: IN AN EMERGENCY, ONE WITH HEART HAS MY PERMISSION TO OBTAIN MEDICAL TREATMENT FOR MY CHILD, CALL AN AMBULANCE OR TRANSPORT MY CHILD TO ANY AVAILABLE PHYSICIAN OR HOSPITAL AT MY EXPENSE, WITH THE FOLLOWING RESTRICTIONS (IF APPLICABLE) MY CHILD MAY BE GIVEN MEDICATION. I UNDERSTAND THE MEDICAL AUTHORIZATION FORM MUST BE COMPLETED AND SIGNED PRIOR TO ADMINISTERING. I UNDERSTAND I MUST CLEARLY COMMUNICATE ANY MEDICATION ADMINISTRATION INSTRUCTIONS AND PERMISSION TO OWH STAFF PRIOR TO CAMP. ONE WITH HEART HAS THE RIGHT TO CANCEL CLASSES DUE TO INCLEMENT WEATHER FOR THE SAFETY OF ONE WITH HEARTS MEMBERS. REFUNDS WILL BE GIVEN FOR WORKSHOPS BUT NO PRORATES FOR ON-GOING CLASSES. MY CHILD MAY PARTICIPATE IN ONE WITH HEART PUKULAN CENTER FIELD TRIPS. I UNDERSTAND VAN OR PUBLIC TRANSPORTATION MAY BE USED. MY CHILD MAY PARTICIPATE IN SWIMMING OR OTHER WATER ACTIVITIES. MY CHILD MAY BE PHOTOGRAPHED FOR WITHOUT ANY PERSONAL IDENTIFIERS IN MARKETING MATERIALS AND MEDIA PROMOTING THE SCHOOL.
Physician's Address *
Physician's Address
Physician's Phone *
Physician's Phone
Date of last Tetanus *
Date of last Tetanus
GET UPDATES AND INFORMATION ABOUT ONE WITH HEART BY SIGNING UP FOR THE E-NEWSLETTER
I would like to know more about: (Check all that apply)