Child Registration for Afterschool Program

Program Dates & Times: beginning September 7 thru May 5, weekly Monday-Thursday, 3pm-6pm.

Locations & Ages:

  • Antioch UMC in Antioch, TN –  elementary and middle school students
  • Matthews Memorial UMC in Madison, TN – elementary students

View full Project Transformation site location information here

*The only cost for the Afterschool Program is a one-time registration fee of $20 per child, or a $50 maximum per family. This fee can be paid online here (make sure to note your child’s name and PT program site location) or by cash or check on the first day of the program.

Please fill out one form for each child you are registering. Limited spaces are available and you may be placed on a wait list if the program fills up.  


forma española




Child's Information:




Parent & Emergency Contacts:


List two adults other than parent/guardian to contact in case of emergency or inclement weather:

Church Contact: I hereby give consent for the site church to use the address on this form to send correspondence regarding upcoming church events.:
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Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19:


The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

Project Transformation Tennessee (PTTN) has put in place preventative measures to reduce the spread of COVID-19; however, PTTN cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending PTTN could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending PTTN and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at PTTN may result from the actions, omissions, or negligence of myself and others, including, but not limited to, PTTN employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any exposure or infection by Covid-19 to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at PTTN or participation in PTTN programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless PTTN , its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of PTTN, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any PTTN program.

By entering your name below, you are effectively signing your signature and acceptance, and that all information on this form is accurate to the best of your knowledge.

* These fields are required.

 


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