Virtual Learning Center Registration Form

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The Virtual Learning Center (VLC) is now OPEN!!!

Please complete each section of the VLC registration form.

We are excited to offer children inside and outside of the community a safe and secure place. Providing a place where children can not only continue to grow academically but socially. While adhering to the Covid-19 rules and regulations, the VLC allows children to be around their peers at a safe distance.

Due to restrictions with the number of persons in the facility registration is required.

We ask that you bring your child's assigned electronics to connect to our FREE WIFI. If you currently do not have a school assigned electronic or home computer please be sure to note that on the registration form.

If your child has any allergies or special requirements please also note that in the additional information section. Safety is our number one concern.

We look forward to seeing you on Mondays and Wednesdays at the VLC!!!

Please use all LEGAL NAMES (as shown on identification), as we will NOT release the child to anyone who does NOT have identification.

Email *

Parent's / Guardians Full Name *

Parent's / Guardians Phone Number *

Parent's / Guardians Full Address, city, state, and zip code *

Child's Full address, city, state, and zip code (if the child does not reside with the parents if it is the same list "same") *

Emergency Contact's First and Last Name *

Emergency Contact's Phone number (format xxx-xxx-xxxx) *

Child/Children's Names and DOB mm/dd/yyyy *

Child/Children's Allergies/Special Needs: Please list their name - allergies and/or special need(s) *

How will your child arrive and leave from the Virtual Learning Center? (select the one that applies) *

I will bring my child and pick up my child from the facility

My child will walk to the facility but I will pick them up after (text message sent once the child(ren) has arrived to the facility in the morning

My child will be dropped off in the morning by a parent/guardian but will be picked up by an authorized person

My child will walk there and walk home from the facility (A text message will be sent to you once your child arrives and leaves the facility)

My child will be dropped off by an authorized person and picked up by an authorized person

My child will be dropped off but walk home (text message sent once they leave the facility to primary parent/guardian)

Do we have your permission in the event of an emergency to contact 911 or transport your child(ren) to an emergency facility? (You and your emergency contact will also be notified) *

Yes

List the person(s) the child(ren) are able to be released to and their phone number. Please list them in priority order. (format xxx-xxx-xxxx) *

By checking the box below, you are adhering to all of the rules and regulations of the After Christ Christian Center and the VLC program. You are acknowledging that everything listed above is correct and true to the best of your knowledge. Also by clicking (signing) below, you are releasing any and all liability of the After Christ Christian Center, it's members, volunteers, and anyone assisting with the program of any liability that the child(ren) may incur including the personal devices. *

Yes, I totally agree and understand

No, I don't understand, and I am requesting to be contacted

Required

A copy of your responses will be emailed to the address you provided.

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