Pray & Play Registration (Fall 2024)

Please complete this registration form (one form per child) to the best of your ability.

Pray & Play is hosted by and takes place at:
Grace Lutheran Church
1140 E High St
Davenport, IA

The program is 8:30am-4:00pm on the dates listed.

Please submit this registration form no later than these dates for each program day:

• The deadline for September 16 is September 10
• The deadline for October 14 is October 8
• The deadline for November 7 is November 1

New this year: there is $10 registration fee for each child for each month they participate. Refunds cannot be given if your child does not attend. Scholarships are available by request- email Pastor Kirsten at pastorkirsten@gracewelcomesyou.org or call her at 563-322-0769. No family will be turned away for inability to pay.

Payment can be made online through a link at the bottom of the registration form. Checks can also be delivered or mailed to Grace Lutheran Church. Payments for all three months can be made at once, or you can pay for each month separately.

If you have any questions regarding the Pray & Play program or this form, please do not hesitate to contact Pastor Kirsten Lee at 563-322-0769 or pastorkirsten@gracewelcomesyou.org.

Grace Lutheran Church provides services to all individuals regardless of race, color, religion, creed, sex, national origin, ancestry, familial status, marital status, age, physical disability, mental disability, gender identity, sexual orientation and any other class that is protected by federal, state, or local law. Special Services are available upon request.

Registration Date

Please check the date(s) you wish your child to attend the program.

All Fall 2024 Dates Monday, September 16 Monday, October 14 Thursday, November 7

IDENTIFICATION INFORMATION

My child has previously attended Pray & Play.

If your child has previously attended Pray & Play, we have your registration information on file, and you do not need to complete anything that hasn't changed. Please complete the required fields and then make any necessary updates, changes, correction, etc.

If your child is new to Pray & Play, please complete all fields to the best of your ability.

Please complete one form per child.

Child's Contact Information

Child's Full Name

Child's Address

Phone

Parent Email

This address will receive a confirmation email

Child's Date of Birth

Child's School

Child's Grade

Child's Gender Female Male Non-Binary

Child's Pronouns She/Her/Hers He/Him/His They/Them

Parent/Legal Guardian #1 Contact Information

Parent/Legal Guardian #1 Name

Parent/Legal Guardian #1 Address

Parent/Legal Guardian #1 Primary Phone

Parent/Legal Guardian #1 Secondary Phone

Parent/Legal Guardian #1 Work Phone

Parent/Legal Guardian #2 Contact Information

Parent/Legal Guardian #2 Name

Parent/Legal Guardian #2 Address

Parent/Legal Guardian #2 Primary Phone

Parent/Legal Guardian #2 Secondary Phone

Parent/Legal Guardian #2 Work Phone

FAMILY INFORMATION

Who does your child live with? Please list names, ages, and relationship to child.

AUTHORIZATIONS

Authorization for Pick-Up

I authorize GLC to allow the following persons to pick up my child from the Pray & Play program. A picture ID must be presented to allow the child to leave. (Please list names, phone, and relationship to child).

CUSTODY/RESTRAINING ORDERS

Are there any custody or restraining orders for the child who may attempt to pick up or have contact with the child while in the care of the center? (Please list name(s) and relationship to your child.)

TRAVEL & ACTIVITY AUTHORIZATION

I give permission for my child to leave GLC with authorized staff for walking field trips. Yes No

PICTURE AUTHORIZATION

I give permission for my child to have their picture taken during special events. I realize these pictures could be used for publicity purposes with the church or online. Yes No

GENERAL QUESTIONS

Has your child had group experiences? (day care, school, church, etc.)

Do they accept new people easily?

What types of activities does your child enjoy?

Does your child have any fears?

Does your child have any nervous habits? (thumb sucking, stuttering, chewing hair, etc)

If your child has nervous habits, when do they show them?

Does your child speak English? Yes No

If no, what is their primary language?

Please tell us about any further information which you believe will be helpful to us understanding your child.

Pray & Play is available to any child regardless of religious beliefs or practices. Because this is a faith-based program, we will pray in various ways and have bible stories. We do so in a way that is inviting and inclusive for the children who are participating. In order to better understand a little about your family’s beliefs & practices, we are asking for you to share information about your family’s beliefs. Please share anything that you feel may be helpful.

DISCLOSURE OF MEDICAL STATUS & EMERGENCY MEDICAL CONSENT

Date of child's last Tetanus shot

My child is (please check all that apply) free of any communicable disease suffers from allergies (list below) is taking medication (please list name of medication, dosage, and reason below) is experiencing the following acute or chronic medical conditions (please list below)

If applicable, please list all allergies (food, environmental, medications, etc.)

If applicable, please list your child's medications (name of medication, dosage, and reason).

If applicable, please list any acute or chronic medical conditions for your child.

Please list any persons to contact in case of emergency if you are unavailable, and who are authorized to pick up your child. (Please list name(s), address, phone, and relationship to your child)

In the event of an emergency, it may be necessary to contact your child's medical provider. Please list who (doctor, dentist, etc) should be notified if an emergency were to occur (list name(s), address, phone.)

This form allows parents and legal guardians to authorize the provision of emergency treatment for the above-named child who becomes ill or injured while under program authority when parents or guardians cannot be reached.

In the event that reasonable attempts have been made to contact me, I hereby give consent for the GLC staff to seek emergency care through calling 911. If hospital care is necessary, Genesis East will be utilized.

This consent will be in effect for one year beginning ___________ (date to be filled in by GLC Staff)

COMPLETED FORM SIGNATURE(S)

I verify that the information on this form is correct. I understand that GLC is NOT able to give any medication to my child.

Signature of Parent/Legal Guardian for Completion of Form (please type your full name as your signature)

Date of Signature

Payment Information

There is a $10 registration fee for each month your child participates. Scholarships are available for any family. Please indicate whether you intend to pay or request a scholarship.

I will pay online I will pay by writing a check. I am requesting a scholarship.

Please follow this link to make an online payment. Choose the "other" category.
Home | Grace Lutheran Church (myvanco.com)

Checks can be payable to Grace Lutheran Church and mailed to Grace Lutheran Church
Attn. Pastor Kirsten
1140 E. High St.
Davenport, IA 52803

*Please indicate on the Memo: P&P & your child's name*

Pray & Play Registration (Fall 2024)

Description

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