New Life Centers – Humboldt Park
KickStart 2010-2011 Registration*
The following information is important in case of emergency. A new form must be used for children with different addresses or guardians. Please fill in every blank.
Parent/Guardian Name: First ______Middle ______Last ______
Social Security Number ______-_____-______SSNs listed are confidential, used for emergency purposes only.
Address ______Phone ______
Check all who live here: __ Parent/Guardian 1 __ Parent/Guardian 2 __ Children listed below
Parent/Guardian 2 Name: First ______Middle ______Last ______
Social Security Number ______-______-______
Address (if different) ______Phone ______
Family Demographics (check in the blank): ____ Black ____ White ____ Latino ____ Asian _____Other
Emergency Contact #1 (not parent/guardian) ______Ph ______
Emergency Contact #2 (not parent/guardian) ______Ph ______
Child 1 Name: First ______Middle ______Last ______Age ______School ______Grade ______
Social Security Number ______-_____-______Relationship to guardian ______
Special Concerns (about school, health, behavior, home, etc.):
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KickStart is a selective program – only a limited number of students will be accepted. Please write why you think this more intensive, academic tutoring would be helpful for your child. *You will be called if your child is accepted into this program!
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Registration Fees: Programs do have costs. We have been blessed with grants, but this year we can’t reapply for one of our major grants. Costs to each child is $40/month – however we are only asking families to pay $10/month or the equivalent amount in another way. Please check which option is best for your family:
_____ I will pay the $10/child or $30/family registration fee each month by the 5th of the month
Checks can be made payable to New Life Centers of Chicagoland.
_____ I will commit to providing snacks for 25 children one day each month/child or 3 days each month/family
A list of program snacks will be sent home (fruit, cereal, granola bars, etc.)
_____ I will commit to selling 2 boxes of candy bars before December 15th/child or 6 boxes of candy bars/family
More information to come about this fundraiser!
By signing below, I release New Life Centers of Chicagoland, New Life Community Church, Chicago Cares, Moody Bible Institute, North Park University and all employees and volunteers of these organizations from any liability. I give permission for my child(ren) to receive necessary medical emergency treatment if needed.
*You will be called if your child is accepted into this program!
Signed ______Date ______
______I DO NOT give permission for photos and videos of my child(ren) to be used appropriately by the program.
______I DO NOT give permission for my child(ren) to participate in religious activities during program times.
______I DO NOT give permission for my child(ren) to go on walking trips to the park and other location in the immediate community with employees /volunteers of the program.