After School Program
2018-2019 Application Form

We exist so East End youth increasingly believe and embody: “We matter. We are maturing. We can make a difference." Because of God and his good news, we practice radical hospitality, authentic relationships, and meaningful opportunities, in order to foster the identityresiliency, and agency of youth in the East End.

The After School Program pairs students with trusted adults who help with homework and encourage positive life choices. Students also receive a full dinner, fun recreation time, and meaningful spiritual instruction.

For Fall 2018, we will offer two evenings of Homework Help + Mentoring (Mondays and Tuesdays, 4PM-6PM) and, for interested students, one evening of Electives (Thursdays, 4PM-6PM). 

Questions? Contact Willis Weber, After School Director
willis.weber@chatrichmond.org or 843.810.9511

STUDENT INFORMATION
Student's Full Name *
Student's Full Name
Birth Date *
Birth Date
SCHOOL INFORMATION
PARENT/GUARDIAN INFORMATION
1. Parent/Guardian Name *
1. Parent/Guardian Name
Cell Phone Number *
Cell Phone Number
2. Parent/Guardian Name
2. Parent/Guardian Name
Cell Phone Number
Cell Phone Number
Parent Involvement *
Parent participation is required for a student to participate in CHAT After School Program. This helps foster open communication and trust among students, parents, and staff. Please check at least two possible areas of interest for your participation:
FAMILY INCOME SURVEY
CHAT is required by the state of Virginia to collect household financial information for every student we serve in order to take advantage of State programs that help fund CHAT’s work. All of the information you provide is confidential.
TRANSPORTATION
CHAT provides transportation from a student's school to After School Programs, and from After School Program to home. If you'd prefer to drive your student, please select that option below.
EMERGENCY CONTACT INFORMATION
Please list 2 Emergency Contacts authorized to pick up student in case of emergency when a parent/guardian cannot be reached.
1. Emergency Contact Name *
1. Emergency Contact Name
Phone *
Phone
2. Emergency Contact Name *
2. Emergency Contact Name
Phone *
Phone
MEDICAL INFORMATION + CONSENT
An answer is required, even if that answer is "No".
An answer is required, even if that answer is "No".
Please make a copy or take a photo of your insurance card (front and back). Submit this to CHAT for faster, smoother medical treatment.
*
THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPANT CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN. By completing and signing this electronic form I the undersigned parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue Church Hill Activities and Tutoring (CHAT), its directors, officers, employees, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have a doctor of medicine or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alteration without the express written consent from Church Hill Activities and Tutoring (CHAT) will cause the participant to be removed from the Program. (revised 6/01/2017)
WAIVERS
*
By completing and signing this electronic form I do hereby authorize my child to participate in any and all activities held by Church Hill Activities and Tutoring, Inc., a Virginia nonprofit organization (“CHAT”). Such activities include but are not limited to the following: tutoring, mentoring, Bible studies, life skills training, arts and crafts, sports, music and dancing, community service activities, meals and snacks and also a series of field trips that could include but are not limited to outdoor activities as well as CHAT-provided transportation to attend these activities. Having authorized my child to participate in CHAT, I further agree as follows: (1) I will not hold CHAT liable for and hereby release any and all claims that I or my child may have as a result of my child’s participation in the above-stated activities. (2) I understand that CHAT may at times need to send and reply to emails, texts, and other electronic messages from youth to communicate about programming; such contact will be limited to programmatic hours. (3) I understand that most of CHAT’s activities will occur at one of the facilities in the Church Hill neighborhood listed below). I hereby agree that my child has permission to attend the CHAT activities at the following locations and I further agree not to hold any property owner liable for and hereby release any and all claims that I or my child may have for any liability against the property owner that results as a part of my child’s involvement in CHAT: CHAT Properties, LLC 3015 N St, Richmond, VA 23223 // Front Porch Cafe 2600 Nine Mile Rd, Richmond, VA 23223 // Gerry Nixon 2410 Venable St, Richmond, VA 23223 // Robinson Theater 2903 Q St, Richmond, VA 23223 // Bethlehem Baptist Church 1920 Fairmount Ave, Richmond, VA 23223 // Carlisle Ave Baptist Church 2010 Carlisle Ave, Richmond, VA 23231 // Peter Paul Development Center 1708 N 22nd St, Richmond, VA 23223 (4) I fully understand that the program involves volunteer mentors, who shall be selected from the community and will be screened (including a criminal background check) and trained before beginning in the program. (5) I grant permission for any photographs and videos taken of my son or daughter participating in CHAT activities to be included on CHAT’s website and in its promotional materials. *In the event I wish to revoke any part of the permission granted hereunder or cancel any part of this agreement, I agree that I will provide a notice of such revocation in writing to CHAT [3015 N St. Richmond, VA 23223] and that the provisions of this agreement shall remain in effect until the receipt of such written notification by CHAT. *This agreement, and the interpretation hereof, shall be governed exclusively by its terms and by the law of the Commonwealth of Virginia, without reference to its choice of law provisions. This agreement sets forth all of the promises, agreements, conditions, and understandings between the parties respecting the subject matter hereof and supersedes all prior negotiations, conversations, discussions, correspondence, memoranda, and agreements between the parties concerning such subject matter.
Today's Date *
Today's Date
 

If you would like to fill out the application by hand, please download or print the form below
and submit at the CHAT Office located at 3015 N St. Richmond, VA 2322.