Safe Haven Sign Up Student InformationStudent Name *Name of the Student who will be attendingGrade Level *Sixth GradeSeventh GradeEighth GradeDate of Birth *Your child's birth dateStudent Phone NumberPhone number for the student, if availableGuardian InformationParent or Guardian Name(s) *Name of Parent(s) or Guardian(s) For the StudentsGuardian Contact Phone *Phone number for the guardianGuardian's Email Address *Email address for GuardianStudent PickupPickup Preference *Drive - with anyone the student knowsDrive - guardian onlyWalk - Student can leave on their ownHow you would like to have your student get home afterwardsPickup RulesYou must make sure that your student will be picked up on time. If you fail to be considerate of our volunteers this way, we may decide to suspend your student from the community.Pickup RulesYou must be sure you are present at the church to pick up your student when the program ends for the day. If you fail to be considerate of our volunteers this way, we may decide to suspend your student from the community.Pickup RulesStudents are free to leave any time. We will contact you if they leave early, so that you know where they are. Once a student leaves for the day, there is no re-entry until next time.Medical InformationMy student has food allergiesList Food Allergies *My student has drug allergiesThis is primarily in case we must administer first aid.List Drug Allergies *My student has a medical condition that affects play or carePlease Explain *Is there anything else we need to know to care for your student while with us?0 / 180Additional Emergency ContactIf we can't reach you in an emergency, is there someone else to call?Emergency Contact PhonePhone number for the contactAcknowledgementsI have looked over the PolicyClick here to view the Policy.I am available to contact during the time the community meetsContact Preference *Phone callText MessageEmail (MUST CHECK IT OFTEN)How is the best way to contact youI will pick up my student on time.My student understands English well enough to participateSubmit Application Form
