Passages Enrichment Program 23/24

To register for Afterschool program, please complete all questions. Some of the information is about your child, some is about YOU, the parent.

This is required information for our funders.

If you want to register additional children, please complete a new form for each child (or contact us)

Which services are you interested in?

Before care serviceAfter care serviceBoth

15. Street Address (Example: 2838 N. Peterson Ave.)

16. City

17. Zip Code (must live in Chicago)

21. How many people are in your family?

22. What is your currently monthly income? (Example: $1,500) This information is required by our funders - our program is free for people of all incomes.

Section 2

Parent/Guardian Information

Please enter information for one of this child's parents or guardians

23. Parent / Guardian First Name

24. Parent / Guardian Last Name

25. Parent Date of Birth

26. Parent / Guardian Telephone Number

27. Parent / Guardian Email address

28. Relationship to Child

MotherFatherGrandparentGuardian

29. Parent / Guardian Country of Origin (home country)

30. Parent/guardian Ethnicity

Hispanic/LatinoNon-Hispanic/Non-Latino

32. Native Language

33. What was the highest level of school you attended? (Example: 9th grade, Master's Degree, Graduated High School)

34. Was that in the U.S. or in your native country?

35. Do you have a library card?

36. Employment Status

37. Please click if you are interested in receiving information about any of Asian Human Services' other programs

Section 3

Emergency Contact

Child's Emergency Contact

38. Emergency Contact Full Name-Relationship

39. Emergency Contact Phone Number

Section 4

Parental Consent

Please complete this section to give consent to these different program requirement.

40. Driving Consent I hereby grant permission to the AHS Afterschool Program to take care of my child when she/he/they is in or out of he program site, 2838 W. Peterson Ave., including riding buses or in cars while travelling to or from said activities and library visits.

I agree

41. Medical Consent I understand that there is a risk of my child being injured while playing or doing an activity. If a parent/guardian or emergency contact CANNOT be reached in an emergency, I give permission to the AHS Afterschool Program to hospitalize and secure proper treatment for my child in case of an accident or sudden illness. I agree that I shall remain responsible for all expenses relating to such medical care and treatment.

I agree

42. Please give the NAME of your child's doctor or hospital (example: Dr. Jan Smith, Swedish Covenant Hospital).

If you do not have this information, please type "don't have"

43. Please give your child's doctor or hospital phone number (example: 773-555-5555).

If you do not have this information, please type "don't have"

44. Photo Consent I give permission to the AHS Afterschool Program for the use of any and all photos in which my child or I may appear
(Photos are often shared privately with funders as proof of activities done by students so our program can receive funding. If you have any questions about our photo policy, please let us know.)

I agree

45. Child Walk-Home Permission My child has permission to walk home alone or with siblings from the Afterschool Program.

YesNo

46. Child Pick-Up Authorization - Parents / Guardians Please write the NAME, RELATIONSHIP, and PHONE NUMBER of parents/guardians who are authorized to pick up this child. EXAMPLE: Mandy Bozart, Mother, 773-555-5555

Name

Relationship

Phone

47. Child Pick-Up Authorization - Friends or Other Family Please write the NAME, RELATIONSHIP, and PHONE NUMBER of other adults (friends or family members) who are authorized to pick up this child. EXAMPLE: David Gearhart, Grandfather 773-555-2222

Name

Relationship

Phone

Section 5

Technology Survey

48. Does your child have internet access at home?

YesNo

50. How can we best reach you with information about the afterschool program? (Links to our Zoom meetings, parent meeting schedule, sharing information with tutors and staff...)

50a. Please provide contact email

50b. Please provide contact phone number

Section 6

Signature

56. PARENT OR GUARDIAN'S STATEMENT:
I certify that the above information is correct. I give my permission for the above named (the child) to participate in this program and agree that my child and myself will follow all program requirements.

Please type your full name (parent/guardian) to sign the form.

57. Please put today's date

Contact Information