We Rise After School Registration Form

Student Information

Student’s Name

First Name Last Name

Birth Date

Month Day Year

Grade

School Attended

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Information

Name

First Name Last Name

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Alt. Phone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Special permissions for Sewing and Cooking class. By choosing to participate in the Sewing and Cooking classes the following injuries may occur such as; burns, cuts, scrapes, finger pricks and any other injury related to these activities.

Sewing Cooking

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by In School/ After Scool Programming at the IHC Flyod B. Simmons Center located at 29150 Carlysle, Inkster, MI, 48141. I understand that in some cases transportaion will be provided and the We Rise Inkster Collaborative may assume the cost of transportation as directed under organizational guidelines. In exchange for the acceptance of said child’s candidacy by We rise Inkster Collaborative. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless We rise Inkster Collaborative and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against We rise Inkster Collaborative including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. Your child will be sent home for inappropriate behavior such as but not limited to fighting, insubordination, or inappropriate sexual conduct. The parent/ guardian will be responsible for any expenses required to transport the child home.

Confirmation BY ACKNOWLEDGING AND SIGNING IN THE BOX BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

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