ROCK PAPERWORK CHECKLIST - ROCK Really Outrageous ...
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ROCK PAPERWORK CHECKLIST
Thank you for registering for the ROCK Before/After School Program, a ministry of
Zionsville United Methodist Church. Please make sure you have each of the following
documents completed before turning in your paperwork:
____ Registration Form
____ Parent Notice
____ Immunization Form
____ Bonus Day Form
____ Discipline Policy
____ Medication Form
____ Medical Consent
____ Waiver and Release of Liability
I, the undersigned, have received and completely filled out all the requested
documents, listed above.
___________________________________________
Parent/Guardian Signature Date
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)REALLY OUTRAGEOUS CHRISTIAN KIDS
A MINISTRY OF THE ZIONSVILLE UNITED METHODIST CHURCH
ROCK is a Christian program serving all families by meeting their physical, emotional and spiritual needs.
REGISTRATION FORM
Before and After School Care
2019-2020
Child’s name ___________________________________________ DOB______________________________
Grade for School year 2019-2020 __________ M/F T-shirt Size ________Child’s Age: ___________
Address________________________________________ City: ____________________ Zip _____________
Home Phone: _____________________ Mother’s Bus/Cell: _________________________________
Father’s
Parent’s Home Phone: (if different) _____________________ Bus/Cell Phone_____________________________
Mother’s Name: ____________________________ Father’s Name: __________________________________
Parents
Address: (if different) _______________________________City: _________________ Zip __________________
School Attending: ___________________________________________________________________________
Parent’s Email address: ______________________________________________________________________
See Back for fee schedule
AM ROCK (6:45am-9am) Check days desired PM ROCK (2:30pm – 6pm) Your child’s Start
Monday AM ____ Monday PM ____ Date: ___________
Tuesday AM ____ Tuesday PM ____
Wednesday AM ____ Wednesday PM ____
Zionsville CSC starts 8/7/19
Thursday AM ____ Thursday PM ____ Children’s Learning Prog Starts
Friday AM ____ Friday PM ____ 8/12/19
Emergency contact:___________________________ Phone_________________ Relation_______________
Helpful information:
(Medications, allergies, fears, any known health problems, recent major changes, etc.)_____________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______ (Initial)
I acknowledge that I will need to provide an updated copy of my child’s most recent Immunization
Records by my child’s first day, you or your doctor may fax over a copy to 317-873-2937. Needed for state records
Persons having permission to pick my child up from ROCK: (We do I.D.) _________________________________
Our current church affiliation is with_____________________________________________________________
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)REGISTRATION CONDITIONS AND FEES
I desire to register my child (name) ______________going into grade ______during the
2019-2020 school year for the ROCK Program and hereby accept the agreement as follows:
Registration fees are $100 per child.
Before School care After School Care
# of days Tuition due # of Days Tuition due
Registered for Each Installment Registered for Each Installment
1 $40.00 1 $48.00
2 $80.00 2 $96.00
3 $120.00 3 $144.00
4 $144.00 4 $176.00
5 $160.00 5 $190.00
Full time morning and afternoon fees are $330 per month.
Your registration fee as well as your August 2020 tuition installment is due at the time of registration and is non-
refundable!
I understand that I am making 10 equal tuition installments due on the 1st of each month, August through May (August
paid at registration). Checks are to be made payable to ROCK & put in the “Black Payment Box”. A late fee of $25.00
will be imposed for any payment received after the 15th of the month.
Media Consent: I understand that Photographs/video may be taken at ROCK that could include my child. I give
ZUMC/ROCK permission to use these photographs/videos in publications as well as advertisements. If you have any
concerns please contact Kathy Gibson.
I also understand that no refund will be made for non-attendance. (See Handbook)
In signing, I am stating that I agree with the conditions of registration and can review a copy of
the ROCK Handbook online at rockzumc.org/forms.html.
ADULT:______________________ _____________________________ ____________
Signature (Parent or Legal Guardian) Printed Name Date
SPANISH CLASSES OFFERED
During the school year we also offer after school Spanish lessons. Please inquire in the ROCK office if you would
like to find out more information about these classes.
**********************************************OFFICE USE ONLY***********************************************
ACS __________ FILE _________ MAIL BOX ________ SIGN IN _________ SIGN OUT __________ EXCEL _________
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)PARENT'S NOTICE
State Form 49444 (R / 1-09) / BCC 0035
I understand that this day care ministry is not licensed under the laws of Indiana. However, I understand that
this day care ministry complies with the State rules concerning sanitation and fire safety for the primary use of the
structure in which it is conducted. I understand that it is my responsibility to ensure that the nutritional and health needs
of my child are met while my child is at the day care ministry.
Signature of Parent or Guardian
Name(s) of children enrolled
This notice does not absolve a day care ministry from liability for injury to a child while the child is at the day
care ministry if the cause of the injury is negligence or intentional wrongdoing on the part of the day care ministry or
an employee of the day care ministry.
Name of facility
Address of facility (number and street, city, state, and ZIP code)
CountyROCK BONUS DAYS
2019-2020
Who: All ROCK Participants
What: All day ROCK on the days listed below
When: October 14-18, 2019
February 17 and 18, 2020
May 26, 2020 (possible snow makeup day)
Where: ROCK @ Zionsville United Methodist Church
Details: When registering, please pay for the days your child intends to
come $50 per day
Once you have registered, you are expected to fulfill your financial
commitment whether your child is in attendance or not. NO REFUNDS.
Hours of operation: We will be open from 6:45am – 6pm each of these days.
Breakfast and two snacks will be provided. You must provide lunch for your
child.
Activities: Activities for these days will be similar to our summer program.
I am registering for (insert dates interested in from bold dates above, name &
grade):
Date: ___________ Child’s Name:_________________________ Grade: ____
Date: ___________ Child’s Name:_________________________ Grade: ____
Date: ___________ Child’s Name:_________________________ Grade: ____
In signing I am stating that I agree with the above registration conditions as well
as the conditions stated on the School year Registration form and in the ROCK
handbook.
_______________________________________ ________________
Parent’s signature DateROCK DISCIPLINE POLICY
The philosophy of the ROCK program is to ensure that each participant is provided a
safe, Christian, education environment where children have structured freedom to
explore, experience, and discover various aspects of physical and spiritual growth
with guidance from educationally qualified, caring professionals.
The purpose of the ROCK Discipline Policy is to ensure that each participant
conducts themselves in a manner that will promote and maintain an atmosphere that
nurtures feelings of respect, safety, belonging, and being loved. Obtaining and
maintaining de-sirable behavior from our participants is a shared responsibility
between child, parent, and ROCK staff.
The following is expected of each participant whether they are in the ROCK building,
on the ROCK bus or on an offsite field trip.
Each participant is expected to:
• Show respect for staff and other participants
• Show respect for the Church and its facilities.
• Exhibit self control and an attitude of cooperation.
• Follow the rules and have an attitude of obedience.
• Be encouraging towards others.
Each participant is expected NOT to:
• Use inappropriate language, disrespectful language, or “put downs."
• Bully other children in any way.
The ROCK staff will maintain communication with the parents of children who are
struggling with any behavioral issues.
Participants who choose to continuously cause disruption, disobey, be disrespectful or
cause harm to others will be disciplined accordingly, as follows:
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)1st offense -The child will be taken aside for discussion
2nd offense -Timeout
3rd offense - A letter .will be sent home requesting a conference with the child's
parents in order to create a plan to halt this behavior;
4th offense -The child's parent will be called to pick their child up from ROCK
immediately.
5th offense - The child will be dismissed from the ROCK program until behavior is
corrected. The discussion to allow a child to return is at the discretion of the Director.
This policy may be altered at the discretion of the Director. In signing, I am stating that
I have received and read a copy of the Rock Discipline Policy. I am also stating that I
understand the policy.
_________________________________ _________________________________
Parent/Guardian Signature Date ROCK Participant Signature Date
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)ROCK MEDICATION PERMISSION
_________________________________ ______
Student’s Name Age
A few children experience an allergic reaction to the sting of bees, wasps, hornets,
and/or food. Since allergic reactions can be serious at times and require prompt
treatment, ow medical consultant has recommended that the staff administer oral
Diphenhydramine HCL (“Benadryl”) to children who have been stung or are exhibiting a
reaction to food, dye, or juice.
YES, the ROCK Program is hereby given permission to administer the
medication Diphenhydramine HCL (“Benadryl”) by mouth to my child, named
above, according to the dosage outlined below, in the event that my child is
stung by a bee or wasp at camp or exhibits a reaction to food.
NO, I DO NOT wish for my child to be given oral Diphenhydramine HCL
(“Benadryl”) in case of a bee or wasp sting, or a reaction to food. Please
provide a reason for this decision below.
REASON: _____________________________________________________________
PARENTS MUST FILL IN DOSAGE AMOUNT OR WE CANNOT ADMINISTER THE MEDICATION.
DOSAGE FOR CHILDREN 6-12 YEARS OF AGE (Please check one):
1 teaspoonful (12.5mg)
2 teaspoonfuls (25 mg)
Other ___________________________
DOSAGE FOR CHILDREN UNDER 6 YEARS OF AGE:
1/2 tsp per 10 pounds (Do not exceed 2 tsp)
Dosage Amount ___________________________
YES, my child has had a severe life-threatening reaction to a bee or wasp sting.
Please explain the type and symptoms of this reaction and what needs to be
done. _________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_________________________________ ____________________________________
Parent/Guardian Signature Emergency Phone Number(s)
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)ROCK MEDICAL CONSENT
In the event my child ____________________________ becomes ill or sustains an injury
while attending the ROCK Program, a ministry of the United Methodist Church, Indiana,
I the undersigned give permission to those in charge to administer first aid. I also
consent to an x-ray examination, anesthetic, medical (or dental) or surgical diagnosis
and treatment and hospital care, and the administration of drugs or medicine to be
rendered to my child under the general or specialized supervision and upon the advice
of the duty licensed physician and/or surgeon. I understand that this consent will apply
to all emergency situations present and future, and that a copy of this form is valid as
the original. This consent is to. remain in effect until written revocation is made.
_________________________________ ____________________________________
Parent/Guardian Signature Date
_________________________________ ____________________________________
Address Phone Number
Please describe any health issues:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any medication your child is taking on a regular basis:
(Name of medication, dose, and prescribing physician)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Name of Primary Care Physician ________________________________________________
Phone Number of PCP ________________________________________________
Hospital of Choice ________________________________________________
P.O. BOX 547
Zionsville, IN 46077
(317-733-4081)
Fax (317 873-2937)WAIVER, RELEASE OF LIABILITY, AND CONSENT TO
MEDICAL ATTENTION
ZIONSVILLE UNITED METHODIST CHURCH
9644 Whitestown Rd., Zionsville, IN 46077
317-873-2623 Fax 317-873-2937
LAST NAME: ____________________________ FIRST NAME ______________________
ADDRESS ____________________________________________________________________
CITY _______________________STATE ______________________ ZIP CODE ___________
HOME PHONE: ______________________ EMERGENCY PHONE ____________________
EMAIL: ______________________________________________________________________
EVENT:
Date: August 7, 2019-May 22, 2020
Destination: Transportation to ZWest, Eagle, PVE, Union, Boone Meadow and Stonegate
Schools
In exchange for my being allowed to participate in events sponsored by Zionsville United
Methodist Church (herein referred to as “ZUMC”), I and, if I am not yet 18 years old, my parent
or legal guardian (individually and collectively referred to below in the first person singular)
agree to be bound by each of the following:
1. Obligation to Inspect Facilities and Equipment. I agree that prior to participating in the event,
I will inspect the facilities and equipment to be used. If I believe anything is unsafe, I will
immediately advise the supervisor of the event and ZUMC of such unsafe condition(s) and refuse
to participate in the event.
2. Identification of Risks. I understand the participation in the event may involve risk of serious
injury, including permanent disability and death, and other losses, both to persons and property.
I understand that these injuries and losses might result from the actions, inactions, negligence, or
conduct of others, the rules of the event, or the condition of the premises or of any equipment
used.
3. Assumption of Risk. I assume all risks, known and unknown, in any way connected with my
participation in the event. I accept personal responsibility for any liability, injury, loss or
damage in any way connected with my participation in the event.
4. Waiver and Release. I waive, release, and hold harmless ZUMC and its directors, officers,
sponsors, employees, volunteers, agents, successors, and assigns from all claims for any liability,
injury, loss or damage in any way connected with my participation in the event, whether or not
caused in whole or part by the negligence or other misconduct of ZUMC or any of the
persons mentioned above. I intend for this waiver and release also to apply to any relatives,
personal representatives, heirs, beneficiaries, next of kin or assigns who might pursue any legal
action or claim for such liability, injury, loss or damage.
(over)Furthermore, in consideration of my child's participation in the event set forth above, I hereby
AGREE TO INDEMNIFY AND HOLD HARMLESS ZUMC from any and all claims,
demands, rights of actions or liabilities of whatsoever nature that any person had, now has, may
have or might in the future have against ZUMC, including but not limited to, any and all claims,
demands, rights of actions or liabilities based upon any NEGLIGENCE on the part of ZUMC
based upon, arising out of, or in any manner connected with my child's participation in the event
identified above.
5. Consent to Medical Treatment. I agree that ZUMC may provide to me, through medical
personnel of its choice, customary medical or training assistance, transportation, and emergency
medical services. This consent does not impose a duty upon ZUMC to provide such assistance,
transportation, or services.
6. Media consent. I understand that pictures of the event which may include my child/children
will be available for use in church publications.
I HAVE READ THIS WAIVER, RELEASE, AND CONSENT. I UNDERSTAND THAT I
HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT. I AM SIGNING THIS
WAIVER, RELEASE, AND CONSENT VOLUNTARILY.
ADULT: ___________________________ ____________________________ ____________
Signature (Parent or Legal Guardian) Printed Name Date
MEDICAL INFORMATION
Medical Insurance Provider: _________________________________ Phone _______________
Policy Number :________________________________
Medical Pre-Certification Procedure (if applicable):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Special Medical Information Concerning Patient: (allergies, medications, conditions, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Adopted 4-27-04 ZUMC Church CouncilYou can also read
