student improvement Program Registration

Child's Information

Child's Full Name

First Name

Last Name

Child's Age

Child's Date of Birth

YYYY

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Male

Female

Last DPT

YYYY

School Year/Current Grade

Does your child receive Special Education services at school including IEP?

Yes

Does your child have a mental health diagnosis such as ADHD, Autism, or any other mental health issues?

Yes

If yes, please explain diagnosis:

Medical Information

Please list any allergies and/or medical concerns regarding your child and any special medications necessary for treating concerns, if applicable:

Insurance

Please list insurance company name, policy number and child's Medicaid number

Preferred Hospital

In case of emergency

Primary Care Doctor

Physician Name, Address, and Phone Number

Dentist

Dentist Name, Address, and Phone Number

Parent/Guardian Information

Parent/Primary Guardian Full Name

First Name

Last Name

Relationship to Child

Email Address

Primary Phone

The best number to reach you

(###)

###

####

Secondary Phone

(###)

###

####

Parent/Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Information

Please list your employer's name, company name, location, and phone number

Annual Household Income

How many persons in household?

Medical Treatment Consent

If an accident and/or emergency occurs with the above named child and I am not available immediately, I DO HEREBY AUTHORIZE Lily Missions Center to transport or have him/her transported to a physician/dentist office, or hospital or emergency facility for treatment including transfusions, necessary anesthesia, and those means considered necessary and proper by the doctor/dentist in attendance for the treatment of the patient.

Digital Signature of the Parent/Primary Guardian

Your digital signature recognizes you have read and agree to the terms stated above. Your digital signature is binding.

First Name

Last Name

List of all persons (at least 16 years old) whom child may be released to/accepted from or who may be notified if the parent or guardian cannot be reached in the event of an emergency.

Primary/Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Relationship to Child

Secondary Contact

First Name

Last Name

Phone

(###)

###

####

Relationship to Child

Additional contacts to whom child may be released to/accepted from or who may be notified if primary and secondary contacts cannot be reached:

List first & last name, phone number, and relationship to child for EACH additional contact.

Bullying Contract

Everyone has the right to feel physically and emotionally safe at Lily Missions Center and we do everything we can to create and preserve a safe environment. No physical or emotional assaults will be tolerated. Examples of specific behaviors that constitute bullying: • Punching/Hitting/Slapping • Tripping • Poking (with fingers or other objects) • Pushing or shoving • Pulling on hair or other body parts including clothing • Kicking • Spitting Any bullying, whether cyberbullying, physical, or verbal acts that disrupt the learning environment at any time will result in the following disciplinary actions: 1st offense - There will be a call to primary guardian immediately. If we are unable to reach you, a staff member will speak to the caregiver who picks up your child. 2nd offense - There will be a call to primary guardian immediately. If we are unable to reach you, a staff member will speak to the caregiver who picks up your child. Your child will be suspended from the program for 1 week. 3rd offense - There will be a call to primary guardian immediately. If we are unable to reach you, a staff member will speak to the caregiver who picks up your child. Your child will be expelled from ALL LMC programs for the remainder of the academic year.

Student's Responsibility & Digital Signature

I commit that I will not physically or verbally bully my peers. When I witness bullying, I will report it to an adult. I understand the bullying policy and procedures.

First Name

Last Name

Parent/Guardian Responsibility and Digital Signature

I commit to encourage my child to always respect others. I have instructed my child not to bully. I have advised my child to report any bullying to an adult. I understand the bullying policy and procedures as stated. I understand my digital signature is binding.

First Name

Last Name

Today's Date

YYYY

LMC's "No Handheld Technology" Contract

Please read thoroughly and discuss with your child. Both parent/guardian and child will need to digitally sign the contract below. We at Lily Missions Center want to ensure that time spent at our programs is well spent. To ensure this, we will be enforcing a strict "No Handheld Technology" Policy. This policy ensures that time is productive without unnecessary distractions. We provide many opportunities for children to enrich their minds with learning and other interactive activities, and believe that phones, tablets, portable music players, and video games are a distraction to the learning and growth that happens at our programs. We have a phone in the office that can be used by all students who need to call home for any reason. We ask that NO phones, tablets, or portable music players be brought to Lily Missions Center's After School or Summer Reading Programs. If they are brought, they must stay in a backpack or be placed in the Technology Basket as soon as they arrive. The basket will be kept in the office. If phones, tablets, portable music devices, or video games are out, there will be consequences as follows- 1st offense: Technology device will be taken and placed in the basket in the office. The device will be given to the parent/guardian at time of pick-up with a reminder that the device must remain put away or left at home. 2nd offense: There will be an immediate call to the parent/guardian to come right away and pick up their child. 3rd offense: There will be an immediate call to the parent/guardian to come right away and pick up their child. The child will be suspended from the program for 1 week. 4th offense: There will be an immediate call to the parent/guardian to come right away and pick up their child. The child will be expelled from the program for the remainder of the school year.

Student's Responsibility and Digital Signature

I commit that I will not bring a technology device to any LMC program. If I do, I will leave it in my backpack or place it in the Technology Basket as soon as I arrive. I understand the rules and consequences as they have been described above. I understand my digital signature is binding.

First Name

Last Name

Parent/Guardian's Responsibility and Digital Signature

I have read and understand the above "No Handheld Technology" policy and procedures, and I have discussed it with my child. I have advised my child not to bring their technology devices to the program. I understand my digital signature is binding.

First Name

Last Name

student improvement Program Registration

Faith • Education • Finance