2023-2024 Scintilla Charter Academy Student Registration

By signing below, I agree to the following:

· My child, named below, is allowed to attend Club 3:16.

· Clubs will run concurrent with the school calendar. No clubs on half days.

· I understand it is my responsibility to have my child picked up at the end of Club, or have him/her signed up for ASP.

· I understand that no Club 3:16 volunteer may provide transportation for my child without prior, written approval

· I understand and agree to the COVID-19 waiver below and understand further information is available at: https://www.ignite316.com/covid-19-info

At Club 3:16, we will do everything we can to be compliant with all regulations and ensure your/your child’s safety. We have put in place measures to reduce the spread, but cannot guarantee that you/your child will not become infected with COVID-19.

COVID-19 Waiver: With full knowledge of the risks involved, I hereby release, waive, discharge Club 3:16, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me/my child related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.

By signing via electronic signature method you are agreeing the electronic signature will be given full legal effect under federal and state law as if it were hand written. You are agreeing that you have read and understand the statements listed above.

Parent/Guardian Name

Child's Information

Please enter only one child per form.
Use Child's LEGAL Name, then add Nickname below, where applicable.
*Nickname should be what your child wants to be called at club.

Name

Nickname

Address

Birthdate

Gender Male Female

Grade

Kindergarten 1st 2nd 3rd 4th 5th

Homeroom Teacher

Contact Information

Please enter the BEST Phone Number and Email Address
for correspondence with your child's Club 3:16 Team Leader.

Phone

This address will receive a confirmation email

Parent/Guardian 1 Full Name

Parent/Guardian 1 Phone

Parent/Guardian 2 Full Name

Parent/Guardian 2 Phone

Emergency Contacts

Please list IN ORDER those we will need to call in case of emergency.
Parents will always be called first.

Emergency Contact 1 Full Name

Emergency Contact 1 Relation to Child

Emergency Contact 1 Cell Phone

Emergency Contact 2 Full Name

Emergency Contact 2 Relation to Child

Emergency Contact 2 Cell Phone

Special Instructions

Are there any security / custody issues with your child?

Yes No

Please explain security/custody issues:

Does your child have any special needs (ADD, Autism, Dyslexia, etc.)?

Yes No

Please explain special needs:

Does your child have any allergies (peanuts, chocolate, etc.)?

Yes No

Please explain allergies:

Any other information we should be aware of:

Pickup Information

Indicate how your child will get home on club day

My child will be picked up after club My child is registered for and will attend extended day/after-school program

Pickup Person 1 Full Name

Pickup Person 1 Phone

Pickup Person 2 Full Name

Pickup Person 2 Phone

Other

Is either parent in the military?

Yes No

Church You/Your Family Attends

OPTIONAL Photography and Video Release

Club 3:16 may, from time to time, document the activities of the ministry with photos or videos. By signing below, you agree to assign and grant to Club 3:16, its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.

I approve the above Photography and Video Release

Yes No

If Yes, enter the name of parent/guardian giving permission below (if No, enter N/A)

2023-2024 Scintilla Charter Academy Student Registration

Description

Please Fix the Following