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 2022-23 school year: I am enrolling my child in the following program(s) for the 2022-23 school year: GAP Tutoring | 1st-8th Grade | Monday-Friday 2:30-4:30 Girls Mentoring | 1st-12th grade | TBA Boys Mentoring | 1st-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 Elderly

Volunteer Opportunities (Check all that apply) Volunteer Opportunities (Check all that apply) Preparing/Serving Meals Tutoring/Mentoring Youth Retail Assistance/Stocking Camp Projects/Outdoors Admin/Support Construction/Maintenance

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?

Name of Child

Gender Gender Male Female

Birthdate (eg. xx-xx-xxxx)

Age during session

School Attending

Parent or Legal Guardian Full Name

Home Phone

Work Phone

Street Address

City

State

Zip

1st Choice 1st Choice *Adventure Camp 1 | June 19-23 | 8-12 year oldsAdventure Camp 2 | June 26-30 | 9-13 year oldsJr Adventure Camp | July 5-7 | 7-8 year oldsTeen Camp | July 10-14 | 13-15 year oldsAdventure Camp 3 | July 17-21 | 8-12 year oldsAdventure Camp 4 | July 24-28 | 8-12 year olds

2nd Choice 2nd Choice *Adventure Camp 1 | June 19-23 | 8-12 year oldsAdventure Camp 2 | June 26-30 | 9-13 year oldsJr Adventure Camp | July 5-7 | 7-8 year oldsTeen Camp | July 10-14 | 13-15 year oldsAdventure Camp 3 | July 17-21 | 8-12 year oldsAdventure Camp 4 | July 24-28 | 8-12 year oldsAdventure Camp 5 | July 25-29 | 10-13 year olds

Check all boxes that apply: Check all boxes that apply: Diagnosed ADD or ADHD Nightmares Asthma Autism Sleepwalking Depression Frequent Nose Bleeds Diabetes Epilepsy Heart Disease Frequent Ear Infections Wets Bed

Wets Bed How Often? PLEASE SEND PULL UPS

Should any activities be restricted? Explain:

Are all immunizations current? Are all immunizations current? Yes No

Describe any hospitalizations or surgery (date, reason, problems):

Describe or list any chronic or serious past illnesses (include dates, medications, etc.):

List any known allergies to medications, foods, insects, pollens, inhalants or other: Please note any severe allergic reactions:

Preferred Hospital:

Insurance Name:

Insurance number:

Doctor's Name:

Doctor's Phone Number:

1st Contact Name:

Phone:

Address:

City:

State:

Zip:

2nd Contact Name:

Phone:

Address:

City:

State:

Zip:

List person(s) authorized to pick up your child. (YOUR CHILD WILL ONLY BE RELEASED TO THOSE ON THE LIST.)

Check-In Options Check-In Options South Side Mission - 9 AM Monday for Adventure Camps and Teen Camp, 9 AM Wednesday for Jr Adventure Camp. Camp Kearney - 11 AM Monday for Adventure Camps and Teen Camp, 11 AM Wednesday for Jr Adventure Camp.

Pick-Up Options Pick-Up Options South Side Mission - 3 PM Friday for Adventure Camp, Teen Camp and Jr Adventure Camp. Camp Kearney - 2 PM Friday for Adventure Camps, Teen Camp and Jr Adventure Camp.

Release Release The health history is correct so far as I know, and the child herein described has permission to engage in all prescribed camp activities, except as noted. I certify the emergency information is correct and that I or my 1st or 2nd contact listed will be available if the camper must be picked up from camp early. I will not hold the camp or its employees responsible or financially liable for any injuries or accidents that occur from participation in the camp program. I am willing to accept responsibility and liability for the inappropriate behavior of my child. I will not hold the camp or its staff responsible or financially liable for accidents caused by either my child or another child who is negligent. I understand that my child will receive non-denominational Christian religious instruction at camp. I give my permission for the First Aid Supervisor to give my child over the counter medication if the situation requires it. South Side Mission may use pictures of this child for camp advertising. I agree to use my insurance or medical card in case of medical treatment arising out of camp participation. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child, as named above. Check here if DCFS exempt and list DCFS emergency “permission to treat” number:

Name of person to authorize

Number of person to authorize

Agreed to by:

Date:

Relationship to Child: (parent or legal guardians ONLY)

Has the state of IL put this child on a plan requiring separate bathing and sleeping quarters? (SASS plan) Has the state of IL put this child on a plan requiring separate bathing and sleeping quarters? (SASS plan) Yes No

Ibuprofen Ibuprofen Yes No

Tylenol Tylenol Yes No

Topical Cream Topical Cream Yes No

Sudafed Sudafed Yes No

Anti-Diarrhea Anti-Diarrhea Yes No

Cough Drops Cough Drops Yes No

Benadryl Benadryl Yes No

Cough Suppressants Cough Suppressants Yes No

Antacids Antacids Yes No

Name

Date

Date

Date of Application

Name

Email Address

Message