Youth Application

Almighty Ministries, Inc. (AMI) Youth Application

Program:

Registration & Consent Form (one application per child)

My child will be transported by the following ways:  Driven Bus Walking Bicycling
Name of person to drop off or pick up youth:


Name of Child:
Street Address: Apt. no.: Zip Code:
Name of School : Grade: Reg or Sp. ed. Classes?  Reg Sp. ed
If special ed, please check appropriate disability:  learning emotional behavioral physical
Apartment Name:
Date of Birth: Age: Sex:  Male Female
Origin:  African-American Hispanic Caucasian Asian Other


Mother’s Name:
Street Address: Apt. no.: Zip Code:
Home phone no. Cell no. E-mail:
Place of Employment: Work phone:
Monthly Income: Assistance Programs:  TANF Food Stamps SSI SS Section 8 Housing


Father's Name:
Street Address: Apt. no.: Zip Code:
Home phone no. Cell no. E-mail:
Place of Employment: Work phone:
Monthly Income: Assistance Programs:  TANF Food Stamps SSI SS Section 8 Housing


Guardian's Name(If different than the above):
Street Address: Apt. no.: Zip Code:
Home phone no. Cell no. E-mail:
Place of Employment: Work phone:
Monthly Income: Assistance Programs:  TANF Food Stamps SSI SS Section 8 Housing


Emergency Contact: Name: Relationship:
Home Phone: Work phone: Cell phone:


Authorization to Participate:
I authorize my child to participate in the program, sponsored by Almighty Ministries, Inc. I understand that I am responsible for arranging for my child to have transportation to and from the program or activity. I furthermore understand that I will be immediately notified if my child misbehaves in the program and that serious or persistent misbehavior will result in removal. I agree to be responsible for any damages my child may cause while participating in this program. I give permission for my child to participate in field trips. I hereby release forever the volunteers and staff of Almighty Ministries, Inc. from any liability that my child may sustain while participating in this program which includes going to and from its location. My e-signature below waives all claims of liability.


Authorization for Medical Treatment
My child is in good health and does not have a contagious infection. I will not allow my child to participate in the program if he/she has a contagious disease, or if for some reason I believe that he/she is not in good physical or mental health. I understand that Almighty Ministries, Inc. is not responsible or allowed to administer any medications.
My child is allergic to the following:
My child is on the following medications:
My child  does does not need eyeglasses.
My child  is is not up to date with immunizations.
If I am not present, with my signature, I authorize Almighty Ministries, Inc. to consent to medical treatment for my child at
I understand that Almighty Ministries, Inc. will do everything possible to notify me before any action is taken.


Authorization for Media Release
I grant consent for my child be videotaped, photographed, or audio/digitally recorded for the purposes of public information.


Authorization for Faith-based instruction
I understand Almighty Ministries, Inc. to be a faith based organization. I give consent for my child to receive instruction on the Lord’s Prayer and any other type of faith-based instruction as it pertains to this program.