Child's Full Name

Birthdate

Age

School

Grade

Sex Sex Male Female

Race Race American Indian/Alaska Native Asian Black/African American White Other

Ethnicity Ethnicity Hispanic/Latino Non-Hispanic/Latino

I am enrolling my child in the following program(s) for the 2024-25 school year: I am enrolling my child in the following program(s) for the 2024-25 school year: GAP After School Program | K-12th Grade | Monday-Friday 2:30-5:00 Girls Mentoring | K-12th grade | TBA Boys Mentoring | K-12th grade | TBA

Name

Address

City/State/Zip

Home Phone

Cell Phone

Employer

Employer Phone

Spouse's Name

Spouse's Phone

With whom does the child live?

Marital Status

Hours of Employment or School

Phone of place where the child lives?

Known Allergies

Disabilities

Medical Concerns

Prescribed Medications

Emergency Contact Name

Emergency Contact Phone

Physician's Name

Physician's Phone

Preferred Hospital

Parent/Guardian Name

Date

Alternate Emergency Contact Name

Emergency Contact Phone

Emergency Contact Address

Emergency Contact Relationship

Alternate Emergency Contact Name

Emergency Contact Phone

Emergency Contact Address

Emergency Contact Relationship

All consents given by checking the boxes below refer to the child you are enrolling into this program. All consents given by checking the boxes below refer to the child you are enrolling into this program. Religious Instruction - I understand that South Side Mission offers non-denominational Christian instruction as an integral part of the curriculum and I do authorize it. Photographs - South Side Mission has permission to use my child's image in photos/videos for publicity and promotional purposes. Transportation to Outings - I hereby give consent to South Side Mission staff and volunteers to transport my child to activities located off-site. Walking Outings - I hereby give consent to South Side Mission staff and volunteers to take my child on walking trips in the neighborhood and excursions to places of interest. Activities Release - My child has permission to participate in all the activities involved in South Side Mission programs. If not, please explain on a separate sheet.

Does this child have a SACY plan in place? Does this child have a SACY plan in place? Yes No

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Name

Address

Phone

Relationship

Ibuprofen Ibuprofen Yes No

Benadryl: Allergy symptoms Benadryl: Allergy symptoms Yes No

Cough Suppressants Cough Suppressants Yes No

Sudafed: Allergy symptoms Sudafed: Allergy symptoms Yes No

Tylenol Tylenol Yes No

Anti-diarrhea Anti-diarrhea Yes No

Antacids Antacids Yes No

Sore Throat Spray Sore Throat Spray Yes No

Topical Cream Topical Cream Yes No

Cough Drops Cough Drops Yes No

Peroxide Peroxide Yes No

Children's Motrin Children's Motrin Yes No

Name

Date

Name

Date

Name

Email

Address

City

State

Zip

Church

Home Phone

Cell Phone

Employer/Occupation

Phone

Date of Birth (A copy of your drivers license or ID will be required, prior to volunteering.)

Emergency Contact Name

Emergency Contact Phone

Are you volunteering with a group? Are you volunteering with a group? Yes No

What is the group name?

Name of the lead contact for the group

Group Contact Email

Group Contact Phone

I am interested in working with (Check all that apply) I am interested in working with (Check all that apply) Children/Youth

Volunteer Opportunities (Check all that apply) Volunteer Opportunities (Check all that apply) Preparing/Serving Meals Tutoring/Mentoring Youth Camp Projects/Outdoors

I am available: (Check all that apply) I am available: (Check all that apply) Monday Tuesday Wednesday Thursday Friday Sat Sun

Monday Times Available

Tuesday Times Available

Wednesday Times Available

Thursday Times Available

Friday Times Available

Saturday Times Available

Sunday Times Available

----------------------------

Have you ever been convicted of any criminal violation of any type of sexual misconduct? Have you ever been convicted of any criminal violation of any type of sexual misconduct? Yes No

Please explain:

Have you ever been convicted of any criminal offense (misdemeanor or felony) in a court of law? Have you ever been convicted of any criminal offense (misdemeanor or felony) in a court of law? Yes No

Please explain:

Have you ever been disciplined, suspended, or terminated by an organization due to allegations of sexual misconduct or abuse? Have you ever been disciplined, suspended, or terminated by an organization due to allegations of sexual misconduct or abuse? Yes No

Please explain:

Name/Title

Phone

Name/Title

Phone

Name/Title

Phone

Are you volunteering to fulfill a Community Service hours requirement? Are you volunteering to fulfill a Community Service hours requirement? Yes No

Please provide the total number of Community Service hours to complete:

What is the reason Community Service hours required?

What was the offense that led to the Community Service hours?

When do the Community Service hours need to be completed? (mm/dd/yyyy)

Please list the name and phone number for your supervisor or probation officer:

Please list the county where the offense/arrest occurred.

Have you volunteered or worked for South Side Mission in the past? Have you volunteered or worked for South Side Mission in the past? Yes No

In what location or ministry area?

Date of Application

Parent/Legal Guardian Name

Address

Phone

Employer

Marital Status

Parent/Legal Guardian 2

Address

Phone

Employer

Marital Status

Emergency Contact Name

Address

Phone

Relationship

Approved for Pick Up: Approved for Pick Up: Yes No

Emergency Contact Name 2

Address

Phone

Relationship

Approved for Pick-Up Approved for Pick-Up Yes No

Student Name

Date of Birth

Age

School

Grade

Gender

Race

Ethnicity

Allergies/Disabilities/Concerns

Medications

Can Swim? Can Swim? Yes No

Student Name

Date of Birth

Age

School

Grade

Gender

Race

Ethnicity

Allergies/Disabilities/Concerns

Medications

Can Swim? Can Swim? Yes No

Check Below Check Below RELIGIOUS INSTRUCTION: I understand that South Side Mission offers non-denominational Christian instruction as an integral part of the curriculum, and I do authorize it. PHOTOGRAPHS: South Side Mission has permission to use my child's image in photos/videos for publicity and promotional purposes. TRANSPORTATION TO OUTINGS: I hereby give consent to South Side Mission and volunteers to transport my child to activities located off-site. WALKING OUTINGS: I hereby give consent to South Side Mission and volunteers to take my child on walking trips in the neighborhood and excursion to places of interest. ACTIVITIES RELEASE: My child has permission to participate in all activities involved in South Side Mission programs.

Any sexually aggressive children or youth plan? Any sexually aggressive children or youth plan? Yes No

Signature

Date

Name of Physician Preferred

Phone of Physician

Preferred Hospital

MY CHILD(REN) CAN RECEIVE THE FOLLOWING OVER-THE-COUNTER MEDICATIONS WHEN DEEMED NECESSARY BY SOUTH SIDE MISSION STAFF. MY CHILD(REN) CAN RECEIVE THE FOLLOWING OVER-THE-COUNTER MEDICATIONS WHEN DEEMED NECESSARY BY SOUTH SIDE MISSION STAFF. IBUPROFEN SUDAFED BENADRYL TYLENOL COUGH SUPPRESSANTS PEROXIDE ANTI-DIARRHEA ANTACIDS SORE THROAT SPRAY TOPICAL CREAM COUGH DROPS CHILDREN'S MOTRIN

Signature

Date