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Ray of Hope Haven for Tween Adventures (a Program for Ray of Hope Mission
International, Inc.) Partnership with Augusta Georgia Recreation and Parks at
Dyess Park Recreation Center 902 James Brown Boulevard Augusta, Georgia 30901
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
After-School Enrichment Program-
- Application (Complete pages 1, 2, and 3; return the forms via email to: peace973@bellsouth.net or mail
to P. O. Box 6591 Augusta GA 30916). Parents/Guardians, you will be notified via telephone about your
childs acceptance in the Tweens Program. The activity form is attached on page 4 for your information.
Phone Number: (706)414-2636
Website: www.rayofhopetween.weebly.com
Student Information Form (Grades K-5)
(No Cost to Parents/Guardians)
Student Name ______________________________________________________________
Grade _____ Age______ Gender__________Date of Birth __________________________
Teacher___________________________________School __________________________
Allergies/food allergies, and/or health
concerns:________________________________________
Medications:__________________________________________________________________
_____________________________________________________________________________
Student Name ______________________________________________________________
Grade _____ Age______ Gender__________Date of Birth __________________________
Teacher___________________________________School __________________________
Allergies/food allergies, and/or health
concerns:________________________________________
Medications:__________________________________________________________________
____________________________________________________________________________S
Student Name ______________________________________________________________
Grade _____ Age______ Gender__________Date of Birth __________________________
Teacher___________________________________School __________________________
Allergies/food allergies, and/or health
concerns:________________________________________
Medications:__________________________________________________________________
_____________________________________________________________________________
Student Name ______________________________________________________________
Grade _____ Age______ Gender__________Date of Birth __________________________
Teacher___________________________________School __________________________
Allergies/food allergies, and/or health concerns: __________________
Medications:__________________________________________________________________
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Contact Information:
Parent/Guardian______________________________________________________________
Address_____________________________________________________________________
Home Phone Number_____________________ Cell Phone Number_____________________
Emergency Person__________________________________ Contact Number_____________

List person(s) names who are allowed to pick up your child and the phone number(s):
1.___________________________________________________________________________
2.___________________________________________________________________________
Medical Physicians Name:______________________________
Phone Number:___________________________________________________________
PreferredHospital______________________________________________________________

How will your child get home from Tween Adventures at Dyess Park Recreation Center?
Initial one below:
_____ Vehicle My child will be picked up in a vehicle.
_____ Walker- I give my child permission to walk home with me/adult noted on the form.

Comments:_________________________________________________________________
__________________________________________________________________________
The person noted on the form will pick up my child/children. I give my child permission to
attend Ray of Hope Haven for Tween Adventures Program. I understand that I must make
certain that my
child attends regularly to benefit from the program. If my childs way of getting picked up from
the Ray of Hope Haven for Tween Adventures Program at Dyess Park Recreation Center
changes, I must send a signed note by the parent/guardian with the child or childrens names,
date, and how he or she will be picked up. If my child does not follow the guidelines, then he
or she may be placed on probation or removed from the program. If my child is going to be
absent, I agree to contact the program on the same day my child is absent. I understand that I
am responsible for transporting and picking up my child from the Ray of Hope Haven for
Tween Adventures Program at Dyess Park Recreation Center. If my child is picked up late more
than twice, he/she will be removed from the program. **I understand that services may be
denied to any child who does not adhere to the guidelines or becomes a threat to others in
the program. I understand that the staff cannot administer medication to my child.
** In the event of an emergency and Ray of Hope Haven for Tween Adventures at Dyess
Park Recreation Center is unable to contact you, 911 (Emergency Medical Services) will
be contacted at your expense.
Signature__________________________________________Date_______________________
Comments__________________________________________________________

List one or two things your child needs help with:

___________________________________________________________________
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Liability Release Form for City of Augusta Partnership with the Ray of Hope Mission International, Inc.
(DBA Ray of Hope Haven for Tween Adventures Program)- Form Revised July 20, 2016
Name of child/children
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. ._________________________________________________________________________________
4. _________________________________________________________________________________
Schools Name______________________________________ Date ________________________________
The Augusta Georgia Recreation and Parks Partnership with Ray of Hope Mission International, Inc.
DBA Ray of Hope Haven for Tween Adventures has organized activities for Tween Adventures at Dyess Park
Recreation Center 902 James Brown Boulevard Augusta, Georgia 30901.

As a parent or guardian of the above minors youth and participant in the above Tween Adventures Program, I do
hereby release forever discharge and agree to hold harmless Ray of Hope Mission International and the City of
Augusta Directors, Officers, and Volunteers thereof from any and all liability, claims, or demands for personal
injury, sickness or death, as well as property damage and expenses.

This release also covers: Permission to use pictures, videos, and voice recordings for past, present, and
future use for my children attending the said program above for lawful purposes only-website,
newspaper, and advertisement for the business; transportation provided by the Ray of Hope Mission
International and the City of Augusta and its representatives for the Ray of Hope Have for Tween Adventures
group who are properly licensed to drive in the state of Georgia: and meetings at Dyess Park Recreation Center
or any other sites during the programs and activities, and breakfast, lunch, and refreshments donated by food
businesses or purchased by the Ray of Hope Mission International, Inc. that will be served at the above
program: And Consent for emergency Medical or Dental Treatment, including examination, diagnosis,
treatment, anesthetic, and surgical treatment, the undersigned agrees to pay for all costs and expenses. Please
ensure all allergies including food allergies, or medical problems or medications are documented on this form
and the application.
The Volunteer Staff is not allowed to administer medications.
This Liability Release Form will remain in effect as long as the named minor child/youth/Tween is a participant
in the program, or the child/youth/Tween reaches adulthood at 18 or parent/guardian voids this agreement in
writing and submit to the Ray of Hope Mission International, Inc. Program DBA Ray of Hope Haven for
Tween Adventures.
If applicable, All Medical Information, illnesses, medications, insurance company/companies, preferred
hospital(s), emergency contact numbers are all listed on the application(s) for my child/children.

I have read the above and understand the information:

Parents/Guardian Please Print Your Name:
__________________________________________________________Date____________________________
Signature of parent/ guardian _________________________________________________________________

Signature of Tween Volunteer/Leader

Date Received__________________________________________________________________
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Ray of Hope Haven for Tween Adventures (a Program for Ray of Hope
Mission International, Inc.) Partnership with Augusta Georgia Recreation and
Parks Program at
Dyess Park Recreation Center
902 James Brown Boulevard Augusta, Georgia 30901
Phone: (706)414-2636; web address: www.rayofhopetween.weebly.com; email: peace973@bellsouth.net

After-School Enrichment Program dates, September -December 2017

Tuesday and Wednesday, 3:15-6:00 p.m.:
o September 12, 13; 19, 20; 26, 27
o October 3,4; 10, 11; 17, 18; 24, 25; 31
o November 1; 7,8; 14, 15
o December 5, 6; 12,13
Note: Dates for January June 2018, will be distributed October 2017.

Super-Saturdays, 9:00a.m.-1:00p.m.:
September 23, October 28 , November 18 , December 16
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Note:
This program is provided at no cost to the parent/guardian. Only students
with a completed application signed by the parent/guardian will be
considered for the program.
Note: A healthy snack will be served for participants.
Children who participate must attend the program regularly (not miss
more than two times).
Transportation will not be provided. Therefore, the parent/guardian is
responsible for ensuring the child or children report to the Tween
Adventures Program at Dyess Park Recreation Center. Students must be
signed in and out and picked up by the parent/guardian or the person
noted on the application.
Our Learning Stations include- Champion teaching Godly Principles and Values, Bowling

indoors , Thinking Outside the Box , Dining Etiquette

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Skills and Manners, Leadership Skills, Hands-on activities, Arts and Crafts,
and 30 minutes Homework-Helper!!