Cool Kidz Registration | Restoration Hall

Thank you for your interest in Restoration Hall. The Restoration Hall is a faith-based organization that seeks to enhance adolescent/ young adults by providing life-skills, enrichment, and/or job readiness training and job placement, through community connections and programming; so that they too can live a new life that will honor God through their purpose. Below is the membership application for our Programs. Please fill out the form in its entirety.

If you have any questions, please contact the administrator at info@restorationhall.com

Program of Interest

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age

Child's Shirt Size

Child's Race

Child's Primary Language

English

Spanish

French

Other

Address

Child's School

Child's Grade

School Lunch

Free

Reduced

Full Pay Lunch

Who does the child live with most of the time?

Child's Physician

Child's Special Medical Needs (If applicable)

Please list any medical condition including allergies

Can your child swim?

Yes

No

Primary Guardian's First name

Primary Guardian's Last name

Guardian's Email Address

Primary Guardian's Email Address

Household Income

Additional Guardian First and Last Name

If there is no additional guardian please type "n/a"

Additional Guardian's Phone Number

If there is no additional guardian please type "n/a"

Additional Guardian Email Address

If there is no additional guardian please type "n/a"

Additional Guardian's Place of Employment

If there is no additional guardian please type "n/a"

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Additional Emergency Contacts

Child May be Released to (please include full names and numbers)

Child May Not be released To (Please include full names and numbers; documentation may be required)

If you have documentation why a child should not be released to someone please upload document here.

I hereby give my permission for my child to leave the Center under the supervision of the Center Leader for any activity within walking distance and/or using Restoration Hall transportation. I will not hold Restoration Hall responsible in case of an accident. I understand that if participants leave the meeting place, notice of where they are going will be posted. They will return within meeting time unless prior notification is given. Permission is granted to use current year photographs of my child(ren) in future publications. I agree to abide by rules for members and parent conduct. I understand Restoration Hall is not responsible for loss of personal property. Information which identifies my child cannot be revealed unless I sign a release form for that purpose. I understand that there are NO REFUNDS provided for membership, fees, programs from Restoration Hall, Inc once the program starts.

Single choice

I Agree

I Do Not Agree

Signature

Date

Month

Day

Year

C.O.O.L Kidz

Intrest Form