After School Registration

Noah After-School (Grades 1-5) is a free after-school program emphasizing homework help, Biblically-based character development lessons, & social-emotional support . HCM currently operates NAS sites at our partner churches: Ebenezer Temple & Glory Chapel. Each site is overseen by two staff members who support consistent weekly volunteers. Volunteers work with a group of 3-4 students each day to help with homework & activities.

Nehemiah After-School (Grades 6-8) is a free after-school program that consists of homework help, character development, and social-emotional support for students. Two staff members oversee up to 16 students each day at this after school site which meets at our location on Vine St.

Hartford City Mission's After School Sites run from the third full week of September to Memorial Day, from 4:00 - 6:00 PM daily. For more information on our After School Programs please contact our Executive Director Victor J. Rush.

Fill out the form below to start the registration process for Noah/Nehemiah After School.

Parent or Primary Guardian Info

* Indicates required field

Parent/Primary Guardian Name *

First

Last

Parent/Primary Guardian Email *

Parent/Primary Guardian Phone *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Information

If you have more than one student, you don't have to fill out the whole form multiple times. Once you submit this form for one student, you can click here (this link will pop up after submitting) for additional students.

Student Name *

First

Last

Birth Date *

Program *

Gender *

T-Shirt Size *

Church Group *

Drop Off/Pick Up Information *

Is allowed to walk home Is allowed to be picked up by parent/guardian or emergency contacts

Program Attendance
Our after school programs begin at 4:00pm each afternoon Monday - Friday. Camp starts at 1pm each afternoon Monday - Friday. Young Life is on Tuesdays at 6:30pm. Please fill out the below information for your child accordingly.

Arrival Time *

Medical Information
Please fill out the section below as thoroughly as possible to help us best serve your child.

If your child has any allergies, enter them in the text box. If not, type N/A *

If your child were to come in contact with their allergen, how would you deal with the situation? If your child does not have any allergies, type N/A. *

What medications does your child take? If none, type none. *

What special needs (medical conditions, disabilities, learning issues) does your child have? If none, type N/A *

School Information
We do our best to co

School *

Grade *

Teacher *

Please indicate if their are any changes we should know about to your child's schedule due to COVID (i.e. doing online schooling, hybrid online-in person schooling, etc) *

Emergency Contact Information

List 2 emergency contacts that are not the parent or primary guardian.

Emergency Contact 1

Name (EC1) *

First

Last

Phone Number (EC1) *

Relationship to Child (EC1) *

Emergency Contact 2

Name (EC2) *

First

Last

Phone Number (EC2) *

Relationship to Child (EC2) *

Comment *

Permissions & Agreements

Prior to your child starting program, you will be asked to sign the following agreements.

I give my permission to the school district to release my child's records to Hartford City Mission.
I understand my child may be photographed or recorded on video to be used for memorabilia and program promotion. You have my permission to photograph and videotape my child or display samples of his/her work.
I understand that my child may need to be transported to various sites within the state of Connecticut for field trips and other programmatic events. Children will only be transported by licensed staff. I give Hartford City Mission staff and/or volunteers permission to transport my child for program activities and release the staff and/or volunteers from any liability.

By hitting the submit button below you are acknowledging agreement with the following statements:

I understand that placement in this program is not guaranteed and space is limited.
I understand that in order for a child to have an excused absence, I must inform the program by 3pm.
I understand Hartford City Mission reserves the right to remove students based on conduct and/or attendance.
I understand that I am responsible for my child's transportation to and from program.
I understand that Hartford City Mission's programs use lessons that are Biblically based and my child will be exposed to and participate in Christ-centered activities.
I understand that my registration is not complete until all paperwork has been completed and submitted including a physical dated within the last 2 years.

Submit

Fill out the form below to start the registration process for Noah/Nehemiah After School.

Parent or Primary Guardian Info

Student Information

Emergency Contact Information

Permissions & Agreements

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