Hero Academy After School Club Drop-In Application – New Victoria Baptist Church Kids Ministry

Child's Information

Please fill out this form in its entirety. Incomplete forms may delay the processing of your application.

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Child's Age *

Grade Level *Please select the grade your child will be in this fall

Home Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Best Contact Phone NumberWill be used to communicate program acceptance and any important announcements

Best Contact Email AddressWill be used to communicate program acceptance and any important announcements

Child's School

Alternate Transportation REQUIRED *I understand I will be required to arrange transportation for my child.Transportation is ONLY provided from Boston Elementary at this time. Transportation from any other school is the parent’s responsibility.

School Name

Days my child will attend *Drop-In ONLYDrop-In Only

We would like to attend dinner and the Wednesday night Bible programsYESThe program runs from 6:00 PM to 7:45 PM each Wednesday. Dinner is provided. Kids will go to Hero Head Quarters Bible Study and parents will go to adult Bible study.

Does your child currently attend another after-school program/club? *NoYes

Name of program/club *

Child's Living ArrangementBoth ParentsMotherFatherOther

Other: Please Explain

Child's Legal Guardian(s)Both ParentsMotherFatherOther

Other: Please Explain

Father's Information

Father's First Name

Father's Last Name

Father's Cell Phone Number

Father's Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Father's Employement StatusEmployedUnemployed

Father's Employer *

Father's Work Phone Number

Employer's Street Address

Employer's Apartment, suite, etc

Employer's City

Employer's State/Province

Employer's ZIP / Postal Code

Mother's Information

Mother's First Name

Mother's Last Name

Mother's Cell Phone Number

Mother's Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mother's Employement StatusEmployedUnemployed

Mother's Employer *

Mother's Work Phone Number

Employer's Street Address

Employer's Apartment, suite, etc

Employer's City

Employer's State/Province

Employer's ZIP / Postal Code

Emergency Contact Information

(Person to be contacted if parents cannot be reached)

Name *Please enter First AND Last Name

Relationship *

Phone *

NamePlease enter First AND Last Name

Relationship

Phone

Child's Doctor or Clinic

Phone

My child is currently on medication(s) prescribed for long term use and/or has the following pre-existing illness, allergies or health concerns

My child has the following special needs

The following accommodations may be helpful to meet my child’s needs while at NVBC Hero Academy School Club