After School/Summer Camp Registration

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This field is required

By providing initials below, I give permission to Reaching Our Communicaty Kids, licensed by the Department of Licensing and Registery Affairs to secure emergency medical treatment for the above named minor child while in care..

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By signing below I certify that my child is in good health and my child's immunizations (waiver) are up to date and are on file with the school.

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Parent/Guardian 1

Parent/Guardian 2 (Optional)

List all individuals, other than the parents/legal guardians, to whom the child may be released.

Completing this section is completely voluntary, and all information recorded in this section will be kept confidential. The information will be used by The ROCK for statistical purposes, program assessment, and planning, and may aid in securing program funding through grants.

Your participation in this section is greatly appreciated.


Race *

Check all that apply

American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Prefer not to disclose
This field is required

The school contact will receive a survey at the end of the year from 32N Funding to help us evaluate our after-school program.


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The ROCK Center for Youth Development may revise the Code of Conduct or Release of Liability Statement at any time by updating the pages. You should visit these pages periodically to review the Code of Conduct and Release of Liability Statement, because they are binding on you.

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This program receives funding from the State of Michigan to serve your child. Michigan State University and Public Policy Associates are contracted to evaluate program quality and impacts. By enrolling my child in this program, I agree that the program will share the following attendance and demographic information with the contracted evaluators. All data will be kept confidential.

  • Program
  • Student Name
  • Parent/Guardian Name(s)
  • Parent/Guardian Relationship(s) to Student
  • Parent/Guardian Phone Number(s)
  • Parent/Guardian Email(s)
  • Zip Code
  • Date of Birth
  • Grade Level
  • Gender
  • Race/Ethnicity
  • Contact Name
  • Contact Email
  • Contact Type
By signing below I:
  • Agree to the Parent/Legal Guardian Consent and Authorization.
  • Certify my child is in good health.
  • Certify my child's immunizations (waiver) are up to date and are on file with the school, and agree to provide the immunization record or appropriate waiver with the program upon request.
  • Certify that I accurately completed this form and if anything changes, I will notify The ROCK.
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