Agape Center Faith and Fun Program: 2026-2027

Agape Center After School

Registration and Release Form (Minor)
Thank you for registering your 1st-8th grader in the Agape Center after-school program!

The Agape Center is a safe, supportive place for people to gather and grow mentally, physically, and in their relationships with Jesus. We offer year-round programming and mentorship for kids, teens, and adults in Roseland, Chicago, where we have been serving our neighbors since 1979.

PROGRAM DESCRIPTION: 1st-8th graders will enjoy activities such as academic support (reading and math), gym games, Bible, art, dance, music, and chess.

LOCATION: The Agape Center is at 342 W 111th St, Chicago, IL 60628.
DATES/TIMES: Tuesdays and Wednesdays from 3:00-6:00 PM. The program runs from Teusday, Sept 29th - Wednesday, Dec 9th.

COST: FREE!
Parent/Guardian Information
Your Name
Parent/Legal Guardian
Cell Phone #
Parent/Legal Guardian
Guardian_Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Way to reach you (Parent/Legal Guardian)

Other
How did you hear about us?

Other

Child's Information
Child's Name

First NameLast Name
Ghild's Gender
Child's Age
(as of September 1st 2025)
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Child's School
Child's Grade
Child's Dismissal Time from school?
Any Allergies, medical conditions or special needs?
Is there anything else we should know about your child?

Program Options
Agape Center After School will be offered on Tuesdays and Wednesdays from 3:00-6:00 pm. Please select the days your child will attend."

Program Dismissal
You are responsible for your child after he/she leaves the Agape Center.
Dismissal Preference (Choose One)
Who is allowed to pick up your child?
Please list their names.
Is anyone NOT allowed to pick up your child?
If so, please list their names.
In order for your child to participate, do you need help with transportation to or from the Agape Center?

Emergency Contacts
Name of Emergency Contact #1

First NameLast Name
Relationship to Child
Cell Phone # for Emergency Contact #1
Name of Emergency Contact #2

First NameLast Name
Relationship to Child
Emergency Contact #2
Cell Phone # for Emergency Contact #2

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