After School Matters Program Registration Form 2025

TeenREACH After School Program Registration Form
ICCS offers your community a free after-school program, serving students 11-17. Your child can participate in homework help, sports, arts & crafts, STEM, and service-learning activities. A free snack is also included! For more information contact us at teenreach@iccscares.org.

Please complete the following (one for each child):
Child’s name
Does your child go by a different name/nickname?
Child’s Date of Birth

MonthDayYear
Date
Child's Age
Gender:

MaleFemaleNon-binary
Race

American Indian/Alaskan NativeAsianBlack/African AmericanHawaiian/Pacific IslanderMultiple RacesWhite
Grade this upcoming school year
PARENT/GUARDIAN CONTACT INFORMATION
Parent /Guardian #1 Name
Cell
Home
Work
E-Mail
example@example.com
Mailing Address
Parent/Guardian #2 Name
Cell
Home
Work
E-Mail
example@example.com
Mailing Address
EMERGENCY CONTACT INFORMATION
Emergency Contact #1 (Name and Phone Number)
Emergency Contact #2 (Name and Phone Number)
Does your child have any allergies?
If yes, what allergies do they have?
Does your child have any medical concerns? Please explain:
Is there anything else you would like for the ICCS team to know about your child?
ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM
I hereby assume all of the risks of my child participating in any/all activities associated with the After-School Matters Program including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by ICCS and that it will govern mine/my child’s actions and responsibilities at said activity.

I waive, release and discharge from any and all liability ICCS’ directors, officers, employees, volunteers, representatives, agents, activity holders, sponsors and volunteers from any liability arising from the negligence or fault of the entities or persons released for death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur.

I indemnify, hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract, and I sign it of my own free will.
Name of Child
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION TO OBTAIN AND REVIEW STUDENT RECORDS
I authorize the release of the following information to Illinois Coalition for Community Services on a quarterly basis: IEP, grade point average, photocopies or report cards, school attendance rates, grade achievement information and promotion/graduation information. I authorize the release and exchange of all pertinent information relating to contact with school counselors. I understand that I may revoke this consent at any time revocation must be in writing I understand that no revocation of this consent shall be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications.

Clear
Date

MonthDayYear
Date
All information contained herein is confidential and is for ICCS tracking and reporting mechanisms.

Pursuant to the Charleston Community Unit District #1 policies permitting community organizations to reach a larger audience through the schools, attached is an informational sheet regarding the Illinois Coalition for Community Services. The views expressed in the attached advertisement are solely those of the Illinois Coalition for Community Services and do not reflect the views of or are not endorsed by the school district, any of the Board members, administration, faculty staff or any other persons associated with the school district in any way.
How did you hear about us?

Yard SignFlyerWord of mouthOther
Should be Empty:

TeenREACH After School Program Registration Form

PARENT/GUARDIAN CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

AUTHORIZATION TO OBTAIN AND REVIEW STUDENT RECORDS