The House Of Darla Registration Form

Summer Mentoring Cohort 2023 Session Only*

Full Scholarship/Zero Fee registrations available ( First Come/ First Serve)*
Club House

Mentorship , Life-Skills, & Enrichment
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Mentor Club Registeration
Expected Start Date

MonthDayYear
Date
Expected Departure Date

MonthDayYear
Date
Grade Attending
If other, please explain below
Summer mentoring program dates run from

July 17-Aug 18th

Summer Cohort mentoring membership comes with Tshirt, SWAG KIT, Access to Drop in A.M(11:00-12:30) and/or Drop in P.M. (2:00-3:00) . Peer Group: Activity, Discussion, and Mentoring Club. Option to join Life Skills Club Mondays 1:00-2:00, SWAG: Young Boss Tuesdays 1:00-2:00 , Fit & Fun Wednesdays 1:00-2:00, Discounts on Merch and Concession, Access to Family /Community day event(s)summer only. In addition to discounts to community and family nights for the rest of calendar year 2023*

* some restrictions apply , contact info@Thehouseofdarla.org for more info. In subject put Family and Community nights calendar year 2023*
We would like to sign up for family/ & community night events

YesNoMaybe
Which Mentoring/ Club(s) do you want to register for?

Drop in AM ( 11:00am-12:30pm)Drop In PM (2:00pm-3:00pm)Life Skills ( Mondays 1:00pm-2:00pm)SWAG: Young Boss Series( Tuesdays 1:00pm-2:00pm)Fit & Fun ( Wednesdays 1:00 pm-1:45 pm)Therapeutic Support Services (for individuals qualified for TSS provider services )Support Services ( for individuals qualified for SS provider services)Community Based Life-Skills (CBLS)(for individuals qualified for CBLS services )Sports/CoachingOther
If other, please explain below
Days Interested

MondayTuesdayWednesdayThursdayFridayOther (Saturday)
What days/times of the week are you looking for mentoring
Payment will be due upon acceptance into the program

Full Scholarships and fee waivers are available please see options below.

If you chose zero free clubs please list the clubs interested in below, separate with a comma.
Student Information
T-Shirt Size

SmallMediumLargeXL
First Name*
Last Name*
Gender*

FemaleMaleOther
Race*

Black/African AmericanLatinoWhiteAsianNative American/Alaska NativeTwo or more racesOther
Birth Date*

MonthDayYear
Home Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*
Cell
Work
E-mail*
example@example.com
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home
Cell
Work
E-mail
example@example.com
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I am interested in signing up for afterschool

YesNoMaybe
Other Infomation
Would your child like to be in a club with a friend?

YesNoN/A
If yes, name and age of friend(s)?
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions? If no please enter N/A*
Does your child require any medication? If yes, please list these medications. (we cannot administer medication, please come to the location to administer. ) If no please enter N/A*
In your own words please describe your child ( i.e. shy, outgoing, emotional, likes or dislikes etc) *
Do you give your child permission to walk to programming*

YesNo
Do you give your child permission to walk home from programming*

YesNo
Please list the people authorized to pick up your child. In addition to any other pickup drop-off information. If not applicable please enter N/A*
Does your child have any siblings?*
If yes, what is their age(s)?
Comments
are there any additional comments/ things we should know
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*
Cell*
Work
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
By clicking submit I agree that I have read and agree to the Terms and Conditions*

Yes
Should be Empty:

Club House

Mentor Club Registeration

Payment will be due upon acceptance into the program

Payment Methods

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian