After School/Summer Camp Registration

Your Email

Program

After School

Summer Camps

This field is required

Student Information

Student First name

Student Last name

Gender *

Male

Female

Nonbinary/Some other gender

Prefer not to disclose

This field is required

Birthdate

Grade

Student Phone #

Student Email

Medical and Health Information

Name of Student’s Physician or Health Clinic

Physician’s or Health Clinic’s Phone #

Hospital Preferred for Emergency Treatment (optional)

Medications

Allergies

Physical restrictions

Other Conditions

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..

Draw initials here

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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Address

Address Line 1

Address Line 2

City

State

Zip

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Relationship to Student

Parent/Guardian 1 Phone #

Parent/Guardian 1 Email

Parent/Guardian 2 (Optional)

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Relationship to Student

Parent/Guardian 2 Phone #

Parent/Guardian 2 Email

Emergency Contact (other than parent/guardian)

Emergency Contact Full Name

Primary Phone #

Secondary Phone #

Release of Child (other than parent/guardian)

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

Release of Child Person 1 (Name)

Release of Child Person 1 (Phone #)

Release of Child Person 2 (Name)

Release of Child Person 2 (Phone #)

Release of Child Person 3 (Name)

Release of Child Person 3 (Phone #)

Release of Child Person 4 (Name)

Release of Child Person 4 (Phone #)

Demographic Information

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

Does your student have a disability?

Yes

Does your student qualify for free/reduced lunch (this information helps us maintain funding for the afterschool program)?

Yes

This field is required

School Contact Information

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

Contact Name

Contact Email

Contact Type *

Teacher

Counseler

This field is required

Code of Conduct & Release of Liability Statement

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.

Parent/Legal Guardian Consent and Authorizations

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.

Draw your signature here