STEP (SUMMER TUTORING ENRICHMENT PROGRAM)

Summer Tutoring Enrichment Program (STEP) 2019

CHILD NAME:_______________________________________________________________________

Parent Name_______________________________________________________________________

Does The Child Attend Church:____ Yes____ No. Where____________________________________

__________________________________________________________________________________

This is a Bible Teaching Church an as a part of the Summer Curriculum we will be doing Bible Study (Not Religion) with your child.

Will this be something that your child can participate in ______Yes_____No.

Does the Child Have any Behavioral Problems that we need to be made aware of: ______________________________________________________________________________________________________________________________________________________________________________________

Has your child ever been placed in Robert Davis Center for Children (Detention)_____yes________No

If Yes please state briefly Why and if he/she is still under DYS Supervision_________________________

___________________________________________________________________________________________

Is there a academic subject that your child specifically needs help with__________________________________

TUITION (for the 7 week Summer Program)

One Child $560.00 ($80.00 per week)
One Child (Christ Community Church Members) $490.00 ($70.00 per week)
Family Rates (Must be from same family)
Two children (non-member) = $980.00 ($70.00 per week)
3 or more children (non-member) = $1365.00 ($65.00 per week)
Christ Community Church Members 2 children $840.00 ($60.00 per week, per child)
Christ Community Church Members 3 or more children= $1155.00 ($55.00 per week, per three children)

The Tuition includes: One (1) Shirts per child; breakfast and lunch.

(Each child must bring their own snacks. Cost does not include field trips. You will be notified in advance the cost of the field trips.)

Registration Fee of $25.00 is non refundable. Registration Fee is $35.00 if payment is made by installments. Summer Tutoring Enrichment Program/Christ Community Church is not responsible for items left after the last day of the program. A Child bringing electronic item are fully responsible for them. CCC is not responsible for lost or damaged items

Parent signature Required: ____________________________________

DHR-CDC-1949

AUTHORIZATION FOR THE ADMINISTERING MEDICATION/MEDICAL PRODECURES

Dear Parent/ guardian,

Your written permission is required to administer medication or medical procedures to your child. Any prescription drug or over the counter drug sent to the child Care facility(home/Center) must be in its original container and must be clearly labeled with the child’s name, the name of the drug and directions for administering the drug. A new authorization form is needed each week. If it is absolutely necessary for your child to be given medication while at the child care facility, Please complete the following information.

Child’s Name________________________________________________________________________________

Prescription Number__________________________________________________________________________

Name Of Medication__________________________________________________________________________

Amount of Medication to be given at each dosage__________________________________________________

Instructions (how to give or apply, such as give by mouth, apply to skin, inhale, drops in eyes,ETC.____________________________________________________________________________________

Time and date of last dosage given at home________________________________________________________

Time(s) of Dosage(s) to be given at the child care center______________________________________________

Please give my child the above-named medication at the time(s) and in the amount(s) indicated.

______________________________________

Signature of Parent/guardian Date

To Be Completed by the licensee/staff/caregiver

Date Medication Given	Time Medication Given	Signature of person giving medication

DHR-CDC-739

CHILD’S PREADMISSION RECORD

This Section is to be completed by the child’s parent or guardian. This form is to be kept in the child’s file in the child

Care Facility (home/center).

Child’s Name

Name Child Is known By:

Child’s birth date:

Child’s home address:

Name(s) of Parent(s)/ Guardian

Home Telephone Number( )

Cell phone Number ( )

Address Of Parent’s /Guardian

Mother’s Employer

Father’s Employer

Employers Address

Employees address

Employers phone #

Employer’s Phone Number:

Instructions as to how parents are to be reached in an emergency:______________________________________________

Name	Relationship to child	Address	Telephone number

Name of Child’s Doctor:

Address:

Telephone Number:

( )________________________

Emergency Authorization:

I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for emergency medical expenses occurred. ( If parent/guardian refuses to sign, instructions must be attached stating what procedures the facility is to follow in an emergency.)

_______________________________________/_________

Signature Date

FORM NOT VALID WITHOUT SIGNATURE OF PARENT/GUARDIAN

Page one of two-form not valid without second page

Child’s preadmission record (continued)- page two of two-form not valid without first page

Describe any special needs or Instructions Below:

Person(s) the child maybe released to:

NAME	RELATIONSHIP TO CHILD	ADDRESS	TELEPHONE NUMBER

I understand that the Department Of Human Resources does not inspect activities away from the child care facility (home Or Center). The licensee of the child Care Facility assumes full responsibility for such activities.

________________________________Date_____________

Signature of Parent/ guardian

I give permission for my child to participate in:

(Circle Yes or no and sign each Line)

Activities Away from The Facility

Yes

Signature of parent / Guardian

Date

Transportation provided by the facility

Yes

Signature of Parent /guardian

Date

Swimming/Wading activities provided by the facility

Signature of Parent /guardian

Date

FORM NOT VALID WITHOUT SIGNATURE OF CHILD’s PARENT/Guardian in each space indicated above.

This Section is to be completed by the facility’s Staff

Child’s first day of attendance:____________________ Child’s withdrawal date:____________________

Additional information may be attached

Effective January 22, 2001/Reprinted January2006

Christ Community Church

Parental Release Form

Participant Name: _______________________________________________

Parent E-Mail: ___________________________________________________

Address: __________________________________________________________

Home Phone: _____________________________________________________

Emergency Parent Contact Information

Name: ____________________________________________________________

Home Phone: ____________________________________________________

Work Phone: _____________________________________________________

Cell Phone: _______________________________________________________

Name: ____________________________________________________________

Home Phone: ____________________________________________________

Work Phone: _____________________________________________________

Cell Phone: _______________________________________________________

If a parent can’t be located, who should be contacted in case of an emergency?

Name: ___________________________________________________________

Home Phone: ____________________________________________________

Work Phone: ____________________________________________________

Cell Phone: ______________________________________________________

Does your child have an emotional or behavioral problem? ______Yes ______ No

(If yes, please explain on a separate sheet and advise if he/she is under a doctor’s care for the problem.)

Is this child on any prescription medication? _______ Yes _______ No

(If yes, please list types and reasons for medication on a separate sheet of paper and attach it to the back.)

____________________________________________

Signature- Parent or Legal Guardian only

____________________________________________

Print Name

_______________________________

Date

Does your child have a food allergy? My child ______________________________ has a food allergy to _______________.

PLEASE NOTE: IF CHILDREN ARE LEFT FOR AN EXCEEDINGLY EXTENDED PERIOD OF TIME, and we are not able to locate any approved persons to pick up the child, MADISON COUNTY DEPARTMENT OF HUMAN RESOURCES OR LAW ENFORCEMENT MAYBE CONTACTED.

Christ Community Church

Summer Tutoring Enrichment Program (STEP)

FORM OF AFFIDAVIT FOR PARENT/GUARDIAN

State of Alabama

County of Madison

Before me, a Notary Public in and for said State and County, appeared: ______________________________________________ and is known to me, after being duly sworn or affirmed, says the following:

That affiant is the parent or legal guardian of the minor child/children:

That affiant has been notified by Dr. Earl C. Johnson, a representative if the Christ Community Church/School, that said church or school has filed notice and is exempt under law from regulations by the Department of Human Resources.

____________________________________________________, Parent/Legal Guardian

Sworn or affirmed to and subscribed before me this _______ day of _____________________.

_____________________________ ______________________________

Notary Public My Commission Expires:

2019 STEP Summer Program Staffing

Name	Hours Working	Position
Mary Smith	7:30 – 5:00pm	Program Leader
TBD	7:30 to 1:00pm	Program Assistant
Chastity Wrights	2:00 – 5:00pm	Teacher
Christopher Johnson	2:00 – 5:00pm	Title Nine Teacher
TBD	Various	Program Assistant
TBD	1:00 – 2:00pm (one day a week)	Volunteer Teacher
TBD	9:00 – 11:00am	STEAM Teacher
TBD	5:30 – 7:00	Custodial
Pastor Earl Johnson	Various Days	Program Director
Co-Pastor Linda Johnson	Various Days	Assistant Program Director

Dr. Earl Johnson, Pastor

Rev. Linda Johnson, Co-Pastor

Links

STEP (SUMMER TUTORING ENRICHMENT PROGRAM)