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 Program Director Shontá Browdy.

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

Please note that you can only submit this form for children of whom you are the parent/guardian.

Parent/Guardian Information

* Indicates required field

Parent/Guardian Name *

First

Last

Parent/Guardian Relationship to Child(ren) *

Parent/Guardian Phone Number *

Number of Children Registering *

If you are registering more than one child, you will be redirected to an additional form to submit with each child's information. It does not matter what order you enter your children's information.

Parent/Guardian Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Church, If applicable *

How did you hear about HCM? *

Emergency Contact #1

Cannot be the parent/guardian

Emergency Contact #1 Name *

First

Last

Emergency Contact #1 Phone Number *

Emergency Contact #2

Cannot be the parent/guardian

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Phone Number *

Child Information

Name *

First

Last

Date of Birth *

Gender *

Female Male

School for 2019/2020 *

Grade for 2019/2020 *

Name of Teacher *

Allergies (food, bees, latex, nuts, etc). *

Please indicate what you do if your child comes in contact with their allergen (Epipen, hospital, benedryl, etc) *

Does this child have an IEP (Individualized Education Plan) or a 504 Plan? If so, we would like a copy so that we can do our best to follow your child's approved educational accommodations. *

List any medical conditions/needs that your child has. If none, put N/A. *

Are there any medications that your child takes that may need to be administered in an emergency. If so list them and why they would need to be administered. *

My child is able to arrive by 4:15pm *

Yes No

My child can attend all 5 days of program each week *

Yes No

Site Preference* *

*Spots at each site are limited. Your preference choice does not guarantee that you will be assigned to that site.

Pick up Method *

T-Shirt Size *

Please add anything else we should know about your child here: *

Submit

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

Parent/Guardian Information

Emergency Contact #1

Emergency Contact #2

Child Information

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