After School Program
2017-2018 Enrollment Forms

CHAT offers several different afterschool programs, all of which are led by our team of staff, residents, and volunteers. Meals and/or snacks will be offered at all programs. Our Mentoring program includes homework help and other fun, enriching activities in a one-on-one setting. Our Enrichment Groups give students the opportunity to explore a wide range of activities that could include bible stories and teaching, art and crafts, sports and games, music and dance, sewing, outdoors, woodworking, science experiments, cooking, and more. Youth group offers youth an opportunity to build relationships with peers and adults, and to learn and live the basics of the Christian faith. Field trips and special events may be added outside of these scheduled times, including opportunities for parent participation. Youth group will begin on September 15th. All other programs will begin the week of September 18th
Contact Emiline Lyell with any questions: emiline.lyell@chatrichmond.org // 804-489-3182

Lower Elementary Grades: K-2nd
Mondays: Mentoring at Bethlehem Baptist, program 4-6pm, drop off 6-6:30pm
Tuesdays: Mentoring at Bethlehem Baptist, program 4-6pm, drop off 6-6:30pm
Wednesdays: (K-1st only) Enrichment Group at EEF Offices, program 4-6pm, drop off 6-6:30pm
Thursdays: (2nd only) Enrichment Group at EEF Offices, program 4-6pm, drop off 6-6:30pm

Upper Elementary Grades: 3rd-5th
Mondays: Mentoring at Rez House, program 4-6:30pm, drop off 6:30-7pm
Tuesdays: Mentoring at Rez House, program 4-6:30pm, drop off 6:30-7pm
Wednesdays: Enrichment Groups at Rez House & other locations, program 4-6pm, drop off 6-6:30pm

Middle School Grades: 6-8th
Mondays: Mentoring at Granger Home, program 3:30-6pm, drop off 6-6:30pm
Tuesdays: Mentoring at Granger home, program 3:30-6pm, drop off 6-6:30pm
Wednesdays: Enrichment Groups at Rez House & other locations, program 3:30-6pm, drop off 6-6:30
Fridays: Youth Group at Peter Paul, program 6-8pm, pickup 5:30-6pm, drop off 8-8:30pm

High School Grades: 9-12th
Mondays: Mentoring at the Lighthouse, program 3:30-6pm, drop off 6-6:30pm
Tuesdays: Mentoring at the Lighthouse, program 3:30-6pm, drop off 6-6:30pm
Fridays: Youth Group at Peter Paul, program 6-8pm, pickup 5:30-6pm, drop off 8-8:30pm

Name *
Name
Date *
Date
Date of Birth *
Date of Birth
Grade (2016-2017 School Year) *
ex. Mother/Father
ex. 123 Mockingbird Lane, Richmond, VA 23223
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
Please note the change in time for our afterschool programs this year. CHAT will be offering transportation directly from the schools listed below, to after school programs. If your students’ school isn’t listed, please choose one of the other options (home pickup or parent drop off). Due to the later time, CHAT offers home pickup for youth group. All students will be dropped off at the home address listed for all programs, unless alternative arrangements are made in advance. Please note that CHAT cannot provide transportation to locations outside of the east end of Richmond.
Please select your student’s pickup location:
I, being the parent and/or legal guardian of my child, 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 camping and activities, Gallmeyer Farms Pumpkin Patch, and Collegiate Village Green Fair, etc, 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 most of CHAT's activities will occur at the house of one of the homeowners in the Church Hill neighborhood listed below (each a "homeowner"). 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 homeowner liable for and hereby release any and all claims that I or my child may have for any liability against the homeowner that results as a part of my child's involvement in CHAT:
(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 (1)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 601 N. 31st St Richmond, VA 23223 CHAT Properties, LLC 3015 N St Richmond, VA 23223 Gerry Nixon 2410 Venable St Richmond, VA 23223 Robinson Theater 2903 Q St. Richmond, VA 23223 Paul and Rebecca Granger 1201 N 20th St Richmond, VA 23223 EEF Offices 2906 Q Street 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 child 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 Offices and that the provisions of this agreement shall remain in effect until the receipt of such written notification by CHAT Senior Staff. • 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.
Your name here will serve as an electronic signature.
Date *
Date
Please include the physician, phone, policy holder's name and policy number. Submitting a copy of your insurance card to CHAT (front and back) will expedite 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. I the undersigned participant and 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)
Your name here will serve as an electronic signature.
Date *
Date