Child's Information:

Which program are you registering for?: ^*

Has this child attended a Project Transformation program in the past?: ^*

First Name: ^*

Last Name: ^*

Street Address: ^*

City: ^*

State: ^*

Zip: ^*

Birthdate (MM/DD/YYYY): ^*

Grade (entering Fall 2022): ^*

Gender:

Primary Language:

Race:

Ethnicity:

Dietary Restrictions:

Food allergies:

Does your child have any medical condition(s) that we should know about to best engage with him/her? Please include any medications that you would like us to know about. The staff will not administer medication, but a parent/guardian is welcome to come and give their child medicine.:

Transportation: ^*

School: ^*

Household Monthly Income (1500.00 format, no $ and no comma): ^*

Number of members in household: ^*

Does this child qualify for government assistance or free/reduced lunch program?: ^*

Parent/Guardian & Emergency Contacts:

Parent/Guardian Name: ^*

Parent/Guardian Phone: ^*

Parent/Guardian Email: ^*

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

Emergency Contact #1 Name: ^*

Relationship to child: ^*

Mobile Phone: ^*

Home Phone: ^*

Emergency Contact #2 Name: ^*

Relationship to child: ^*

Mobile Phone: ^*

Home Phone: ^*

Names of adults, other than parent/guardian and emergency contacts who have permission to pick up this child:

Consent & Permissions

Picture/Name Release: I hereby give consent for my child’s picture and name to be used for Project Transformation program and its partner organizations/churches promotional purposes.

^*

Church Contact: I hereby give consent for the site church to use the address on this form to send correspondence regarding upcoming church events.:

^*

Reading Program: I hereby give consent for Project Transformation to track my child’s reading and academic progress this school year. Data may be published in the future.

^*

School Contact: I hereby give consent for Project Transformation Tennessee to share my child’s reading progress with my child’s school and/or school partners.

^*

Participation Policy: I understand that Project Transformation Tennessee is committed to providing a safe and positive learning environment. My child is expected to act respectfully towards other and site property. I understand that disrespect, inappropriate language, fighting, bullying, or damaging property will not be accepted and may result in dismissal from the program. If my child does not follow the discipline policies of Project Transformation Tennessee, he/she will be suspended or expelled from the program.

^*

Attendance Policy: I understand that it is important for my child to attend the program on a regular basis and that; if my child misses the program three days in a row with no prior communication with the Site Coordinator, my child will lose his/her spot on the roster and will be replaced by a child on the waiting list. It is also required that my child attend three of four program days each week.

^*

I understand that Project Transformation programs are located on the premises of partner churches. Additionally, Project Transformation provides supervised and monitored activities including bible lessons, reading tutoring, arts enrichment, meals, recreational activities, and other enrichment components. However, Project Transformation Tennessee sites are not required to be licensed by the state as a child care agency.

^*

I understand that Project Transformation Tennessee does not provide transportation to or from our program. This is the sole responsibility of the parent/guardian. If my child is not walking home, he/she will be picked up every day at 3pm.

^*

I understand that Project Transformation Tennessee and/or the site church cannot be and are not responsible for anything that happens to my child or anything my child does before he/she checks into the program or after he/she checks out of the program each day.

^*

If my child chooses to willfully leave camp during program hours or to not attend the program, Project Transformation Tennessee and/or the site church cannot be and are not responsible for my child’s safety, well-being, or behavior.

^*

I hereby take full responsibility for my child’s whereabouts and actions before and after he/she checks into the program. Thereby, I release and discharge Project Transformation, the site church, or any and all employees, owners, members, officers, agents, representatives, or subsidiaries of any and all claims arising in any way from actions, events, or omissions occurring before my child is checked in and after my child is checked out of the program each day.

^*

I understand that if an emergency involving injury occurs at a Project Transformation program site, 911 will be Immediately called. Emergency personnel will make the determination of whether to transport the child to a medical facility. Every effort will be made to contact the child’s parent or guardian; however, if the parent or guardian cannot be reached, the child will still be transported to a medical facility for emergency treatment. Project Transformation Tennessee is not responsible for costs associated with emergency transport.

^*

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

^*

Summer 2022 Participant Registration

forma española

Child's Information:

Parent/Guardian & Emergency Contacts:

Consent & Permissions

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19:

ABOUT US

HOW IT WORKS

OUR PROGRAMS

GET INVOLVED

Summer 2022 Participant Registration

forma española

Child's Information:

Parent/Guardian & Emergency Contacts:

Consent & Permissions

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19:

ABOUT US

HOW IT WORKS

OUR PROGRAMS

GET INVOLVED

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