2009-2010 Online Registration
To navigate on this form, you can use your mouse, or simply "TAB" to the next space. If you click on your "Return" button, your form will be submitted and you will have to begin again. Thank You!)
First Name: Last Name: Birthdate
Grade (as of beginning of current school year):
If your child is in preschool, please place the year you expect your child to begin Kindergarten:
Any special needs?: ADHDAutismDyslexiaSpeech ImpairmentVision ImpairmentOther: Please list in next box Other Needs:
Allergies: (Food and Medical, please)
Mother's Information: Father's Information:
Guardian/Parent: (Mother):
Guardian/Parent: (Father):
Street Address:
Same:
City:
Zip:
Mother's Cell:
Father's Cell:
Mother's Work Ph:
(If applicable)
Father's Work Ph:
Mother's Email:
Father's Email:
Riverside Members? YesNoWe would like to place membership Which class do you attend? Close EncountersHome BuildersLifelineSojournersOther/ie: Teach/Asst.
According to Riverside's Child Protection Policy, "Children birth through first grades will not released from the classroom without a parent or guardian's express written permission. Nursery parents will receive a pager and/or a numbered tag, which must be returned in order to claim their child. Parents of 2nd through 5th graders may request on this registration form that their children be released only to them. We will do our best to adhere to these wishes:
My child must be picked up by a parent or legal guardian.My child has permission to leave class alone.My child has permission to leave class with the following "authorized" adults or siblings:
Others authorized to pick my child up from class are:
Your name typed in the following blank will be accepted as your authorized signature:
Signature:
From time to time, your child's picture may be taken as part of a special program, brochure or special event. Please read and give your permission by once again "typing your name in the blank" to allow/disallow the following permission:
I give permission on behalf of my spouse and me for Riverside Church of Christ to use photos of my child(ren) and any future children, on the Riverside website, in videos and print publications that will be sent outside the Riverside membership. I understand that my child's name, address, or phone number will never be used in conjunction with his/her photograph in either location. Should there be an occasion when my child's name might be used, such as recognition of my child as last year's award winner, etc., I would be contacted by Riverside staff and would have the option of allowing/disallowing this information to be released.
I/We allow the use of photo(s) I/We don't allow the use of photo(s) as above described