HEARTS REGISTRATION PROCESS
For Graduation Only Membership
2015-2016 School Year
To register, please read through this document in its entirety then submit pages 4-6 along with
payment to the HEARTS Registrar. Once processed, you will receive an e-mail from the
Registrar confirming your membership. If you have any questions concerning the registration
process, you can contact Joan Kirkwood, Hearts Registrar at joan@kirkwoodonline.com
Agreements: HEARTS has a long-held Statement of Beliefs and a Bible-based Standards of
Conduct. In order to ensure that all members of our group have the same firmly held beliefs, we
require that at least one parent and all registered students affirm that they are in agreement with
our Statement of Beliefs. It is the parent’s responsibility to ensure that their students read and
understand this Statement and that they can say that they truly agree with it. Similarly, we
require that BOTH parents and all registered students read, understand and agree to comply with
our Standards of Conduct at all HEARTS activities. There is a line on the Registration Form for
parents to initial to certify this has been done. We greatly appreciate the cooperation of all our
members to help us always to glorify the Lord in everything we do.
Costs: A Graduation Only membership requires a family registration fee. This membership
includes access to HEARTS social and ministry activities, the website, and monthly newsletters.
Additional costs may apply to social activities.
Please send all the forms and checks listed below to our Registrar, Joan Kirkwood, 21120 Blue
Bill Ct., Ashburn, VA 20147.
1.
2.
3.
4.
HEARTS Registration p. 4
Registration Form p. 5
Emergency Contact p. 6
Check for registration
All checks will be made out to HEARTS Treasurer, Enid Trevithick
DO NOT make any checks out to “HEARTS”.
Page 1 of 6
HEARTS Statement of Faith
(At least one parent and all registered teens must be in agreement with this statement)
We believe:
The Bible is the living, inspired, and infallible Word of God (2 Timothy 3:16). It is without error
in whole or in part in its original language and constitutes God the Father’s completed and final
revelation.
In one God, eternally existing in three persons-God the Father, God the Son (who is the Lord Jesus
Christ), and God the Holy Spirit-each of who is equal in being, power, and glory.
In the Lord Jesus Christ, God’s only Son, (John 3:16) His virgin birth, sinless life, sacrificial death
for our sins, His bodily resurrection, and His personal literal return.
That man is saved by grace through faith and nothing of man enters into his salvation; it is a free
gift. Man's efforts, regardless of how good or well intended, before or after salvation, have no
bearing on one’s salvation. Salvation is only by the finished work of Christ. (Eph. 2:8,9)
HEARTS Standards of Conduct
(All registered students must agree to abide by these rules of conduct whenever they
participate in a HEARTS class or activity)
We greatly appreciate the cooperation of all our members in glorifying the Lord in everything we
do. Therefore these Standards of Conduct need to be agreed to by all participating in HEARTS.
“Whether then, you eat or drink or whatever you do, do all to the Glory of God.” I Cor.
10:31
1. SPEECH –
 I will not use any dirty language, crude gestures, gossip, sexual speech, or any speech that is
offensive to my Lord, while at any HEARTS activities or classes.
 I will demonstrate integrity and truthfulness in what I do and say.
“Let no unwholesome word proceed from your mouth, but only such a word as is good for
edification according to the need of the moment, that it may give grace to those who hear.” (Eph.
4:29) “and there must be no filthiness and silly talk or coarse jesting, which is not fitting, but
rather giving of thanks.” (Eph. 5:4)
Page 2 of 6
2. BODY –
 I will not use or have in my possession alcohol/illegal substance/tobacco or weapon at any
HEARTS activity or class.
 I will dress in a manner that is pleasing to my Lord, while at any HEARTS activity or class.
 I will offer to help a teacher, staff member or fellow student when a need arises.
“Or do you not know that your body is a temple of the Holy Spirit who is in you, whom you have
from God, and that you are not your own? For you were bought with a price: therefore glorify
God in your Body.” (I Cor. 6:19,20)
“I urge you therefore, brethren, by the mercies of God, to present your bodies a living and holy
sacrifice, acceptable to God, which is your spiritual service of worship. And do not be conformed
to this world, but be transformed by the renewing of your mind, that you may prove what the will
of God is, that which is good and acceptable and perfect.” (Romans 12:1 & 2)
3. AUTHORITY –
 I will have a proper attitude toward my teachers, HEARTS parents and the GUMC facility.
“Obey your leaders and submit to their authority. They keep watch over you as men who must
give an account. Obey them so that their work will be a joy, not a burden, for that would be of
no advantage to you.”
 I will not pair off or participate in public displays of affection at any HEARTS classes or
events because this can adversely affect the unity within our group.
 I will not listen to any unapproved music, TV, or movie watching at any HEARTS class or
event.
“as obedient students, do not be conformed to the former lusts which were yours in your
ignorance, but like the Holy One who called you, be holy yourselves also in all your behavior;
because it is written, “You shall be holy, for I AM HOLY.” (I Peter 1:14-16)
“Finally, brethren, whatever is true, whatever is honorable, whatever is right, whatever is pure,
whatever is lovely, whatever is of good repute, if there is any excellence and if anything worthy
of praise, let your mind dwell on these things.” (Phil. 4:8.)
4. ACCOUNTABILITY – I am willing to be held accountable for my own actions at all
HEARTS events and classes and will lovingly hold others accountable for their actions.
“and let us consider how to stimulate one another to love and good deeds, not forsaking our own
assembling together, as is the habit of some, but encouraging one another, and all the more, as
you see the day drawing near. (Heb. 10:24-25)
Page 3 of 6
HEARTS for the Lord
REGISTRATION FORM – School Year 2015-2016
Send to Joan Kirkwood, 21120 Blue Bill Court, Ashburn, VA 20147
Parents’ Names _____________________________________________________________
Address ___________________________________________________________________
Home Phone ________________________ E-Mail ________________________________
Your Church _______________________________________________________________
Your Student’s Youth Pastor ______________________Phone or E-Mail _______________
Homeschooled Children registering for HEARTS:
Name
Grade
Birth date
E-mail if different from above
_____________________________
______
_________
________________________________
_____________________________
______
_________
________________________________
_____________________________
______
_________
________________________________
Please initial in front of each statement below as indication that you are in agreement with that
statement:
_____ We have read and understand the HEARTS Statement of Faith (required by both parents
and all students for HEARTS membership.)
_____ At least one parent has been saved by faith, through the grace of God, as a result of
personally accepting Jesus Christ as Lord and Savior. (Agreement of one parent is required for
HEARTS membership.)
______ We and our children have read the Class Registration Procedures and Academic
Expectation and other HEARTS policies and agree to abide by those requirements. (Agreement
required by both parents and all students attending HEARTS classes.)
_____ We and our children have read the HEARTS Standards of Conduct (see below and have
student initial next to each section) and agree to abide by those standards. (Agreement required
by both parents and all students for HEARTS membership.)
Page 4 of 6
REGISTRATION AND LIABILITY INSURANCE FEES
Registration – HEARTS Graduation Only membership allows members to register for the
Hearts graduation, participate in social and ministry activities, and receive the newsletter.
__________ $25 Limited Membership (for those participating in Graduation only.
Scholarship Fund - You also have the opportunity to donate to our scholarship fund. This fund
helps pay the tuition costs for students whose parents are facing financial hardship. Thank you
for considering giving to the fund.
Make checks payable to Enid Trevithick (HEARTS Treasurer)
__________Registration Fee
__________ Scholarship Fund Donation
__________Total Amount
Check No. __________
Page 5 of 6
HEARTS Emergency Contact Information & Medical Consent Form
Complete one form for each registered HEARTS student
Student Name _____________________________________________________________
Address __________________________________________________________________
Mom’s Cell ___________________
Mom’s Work ____________________
Dad’s Cell ____________________
Dad’s Work ____________________
Alternate Emergency Contact Name ___________________________________________
Home Phone ____________________ Work/Cell Phone ___________________________
Medical Conditions _________________________________________________________
Allergies __________________________________________________________________
Medications ________________________________________________________________
Preferred Doctor Name _____________________ Phone ___________________________
Insurer __________________________________ Phone ___________________________
Member Number __________________________ Group Number ____________________
MEDICAL CONSENT/RELEASE
As the parent/legal guardian of ___________________________________________, I hereby
give my consent that in my absence, if I cannot be reached by telephone, the above-named minor
be admitted to any hospital or medical facility for diagnosis and treatment in the event of an
accidental injury or illness. I request and authorize physicians, dentists, and staff, duly licensed
as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to
perform any diagnostic procedures, treatment procedures, operative procedures and x-ray
treatment on the above minor as they deem reasonably necessary. I have not been given a
guarantee as to the results of examination or treatment. I also assume responsibility for the
payment of any such treatment. I absolve HEARTS and its representatives from liability in
acting on my behalf.
I recognize and acknowledge there is no accident coverage nor is there any medical payments
coverage available to me in order to compensate me for expenses I incur from deductibles, copayments, prescription drugs, or medical services not covered through my own health insurance
provider(s) for any injury my child sustains as a result participation in HEARTS activities. I
agree that any medical coverage(s) I have will be primary and under no circumstance will I seek
any contribution from HEARTS, or its insurer, for any medical expenses.
Signed __________________________________ Date ____________________________
Parent/Guardian
Page 6 of 6