Agape Center Faith and Fun Program: 2025-2026

Agape Center Faith and Fun Program: 2025-2026

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: Mondays, Tuesdays and Wednesdays from 3:00-6:00 PM. The program runs from Monday, April 6th - Wednesday, May 20th.

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
CallTextEmialOther
Friend/ReferralFlyersSearch EngineSocial MediaOther

Child's Information
Child's Name*

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

MonthDayYear
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
MondaysTuesdaysWednesdays

Program Dismissal
You are responsible for your child after he/she leaves the Agape Center.
Child is allowed to LEAVE THE BUILDING on his/her own to WALK HOMEChild is allowed to LEAVE THE BUILDING on his/her own to WAIT OUTSIDE FOR PICKUPChild is NOT ALLOWED TO LEAVE THE BUILDING and must WAIT INSIDE FOR PICKUP - ID will be required of adults every time they pick up children.
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

Should be Empty: