After School Program Registration Form



7th - 8th Grade After School Program Registration Form

IMAGINE IF is a free After School Program to provide a safe environment where kids are accepted and loved in Jesus’ Name. We focus on physical, relational, spiritual & academic health. We are a local ministry and not part of SMCSC.

Student’s Name: _________________________________School:__________________

Parent(s) Name: _____________________________Email________________________

Address: ______________________________________City: ___________________

Primary Phone: ______________________ Alt Phone: _________________________

Emergency Contact Name & Number: ______________________ # ________________

Approved for Pick Up besides listed Parent: 1._______________ 2. _______________

Grade _______ Tee Shirt Size: _____ Days Attending Imagine If :________________

NOTE: The Imagine If Program is held at the Pendleton Heights Middle School auxiliary gymnasium & cafeteria. In order to ensure student safety, Parents must pick up student and sign them out in person, anytime between 2:30-5pm. Students must Sign-In.

PARENT/GUARDIAN CONSENT:

Please Note: Any student wishing to participate in the After School Program must have a signed Consent Form on file prior to attending. Students must follow the Rules/Guidelines to ensure each students safety, personal growth and the over-all success of the After School Program. There is no cost, but we will not allow a student of “bad influence” to participate and harm our program.

I, the Parent/Guardian of the above applicant, hereby indicate my approval for him/her to participate in any and all activities of the After School Program. I assume responsibility for all risks and hazards incidental to the conduct of such activities including transportation to the program. I do further release, absolve, indemnify and hold harmless Imagine If, After School Program of Pendleton, it’s parent organization, organizers, volunteers, supervisors, any and all of them, from liability as a result of those risks and hazards. I also understand that my child should have a minor release form signed prior to attending the program. I & my child have read and agree to abide by the Code of Conduct Agreement, a copy of which has been provided for me.

AUTHORIZATION FOR PUBLICATION AND CONSENT TO PHOTOGRAPH:

The undersigned do hereby authorize After School Program of Pendleton to photograph or audio/video tape the students during activities of the program. The undersigned do further agree that they may use or permit “only” authorized affiliates of the After School Program as a “highlight” video or subsequent video for further promotion of the program. A copy of this video(s) can be requested for viewing.

SIGNED: _______________________________________ DATE: _________________

MUST BE SIGNED BY PARENT OR LEGAL GUARDIAN

** Your child can bring this signed form to the program the first day they attend.

IMAGINE IF, INC

MINOR WAIVER/RELEASE

RELEASE OF LIABILITY FOR MINOR PARTICIPANTS

READ BEFORE SIGNING

IN CONSIDERATION OF (Children(s) Name) _________________________________ my minor child/ward (“my child”), being allowed to participate in athletic activities sponsored by Imagine If, Inc. Pendleton, IN 46064, the undersigned agrees that:

1) The risk of injury to my child from the athletic activities are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist, and,

2) FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation; and,

3) I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and,

4) I myself, my spouse and my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE THE other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”). WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property arising from my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.

5) I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

I HAVE READ THE RELEASE OF LIABILITY AND ASSUMPTION OF RISK

AGREEEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I

HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT

FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

____________________________________

Parent or Guardian Date

____________________________________ Parent or Guardian Date

Imagine If – After School Program

Conduct Expectations Agreement

The mission of the Imagine If – After School Program is to provide an environment where kids are safe, loved in Jesus’ Name. Our focal points are: Integrity, Respect, Discipline and Perseverance; improve Self-Confidence and Leadership Skills; emphasize the importance of Education; become more Physically fit; as we share the love of Jesus.

To accomplish these goals, it is essential to establish expectations for conduct and to hold the kids responsible to meet these expectations. We believe the discipline to enforce our basic expectations will minimize problems and maximize the potential for development.

As a participant in the Imagine If – After School Program, I hereby agree to conduct myself with honor at all times. I promise to respect my leaders, my parents, other students and all property associated with the program. I will listen and obey instructions, I will be kind to others and I will not participate in any destructive behavior towards people, the facilities or equipment.

By signing this document below - I understand and accept the consequences of not honoring my leaders, parents, other students and property. I have also “read” with a parent the Rules/Expectations of the Imagine – If Program. I fully understand that not following these rules after signing this agreement will result in my removal from activities, up to removal from the Imagine – If program itself.

Consequences

1st Offense - Private Reminder, spoken in Love

2nd Offense - Temporary Removal from Activity (10 minutes)

3rd Offense – Parent Meeting and Removal from Activity (1-day)

4th Offense - Removal from Imagine – If After School Program

_________________________________________________________________

Student’s Signature Date

_________________________________________________________________

Parent’s Signature Date

Rules/Expectations of Imagine – If After School Program

Respect of Leaders & Parents – listen to & obey authority figures

- Absolutely no talking back or mocking authority

- Following ALL rules (no foul language, no leaving the gym without a leader, bring homework or book everyday)

- Participating POSITIVELY in all activities

Respect of other Students – being kind to each other

- Never touch another student – no “play” fighting

- Never making “fun of” or “bullying” another students

- Never taking equipment forcefully from another student

- Never aiming to “harm” another student – even during dodgeball

- No talking during homework time

Respect of all Property – no destructive behavior

- Never destructive or “wrong use” of equipment

- Never trashing the gym with snacks

- Riding quietly in vehicle to gym – not touching/trashing vehicle

Consequences of Offense

        1st Offense - Private Reminder, spoken in Love

        2nd Offense - Temporary Removal from Activity (10 minutes)

        3rd Offense – Parent Meeting and Removal from Activity (1-day)

        4th Offense - Removal from Imagine – If After School Program

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