Winter Registration Program Application New Participant

2022-2023 Winter Program Registration
Medical Information
Physician Name
Office/Clinic Name
Phone Number
Allergies/Medical Conditions
(please type None if there are none)
Current Medication
(please type None if there are none)
Dietary Restrictions
(please type None if there are none)
Emergency Contacts
Please list all emergency contacts*
*

In the event that I cannot be reached in an emergency, I hereby give my permission to RodneyStreet staff to follow proper Emergency Medical Procedures.
Household Information
Language(s) spoken at home*
Internet access at home*

YesNo
Total household size*
(number of persons living in house of student)
Other family members participating in Rodney Street programs
Total household income level*

Less than $20,000$20,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 or morePrefer not to say
Family Information
(1) Parent/Guardian*

First Name Last Name
Cell Phone Number*

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Email*

Confirmation Email example@example.com
Employer
Occupation
Work Phone Number

Area Code Phone Number
(2) Parent/Guardian

First Name Last Name
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Email

Confirmation Email example@example.com
Address (please change if different from first page)

Street Address

Street Address Line 2

City State

Zip Code
Employer
Occupation
Work Phone Number

Area Code Phone Number

2022-2023 Winter Program Registration
Parental Consent
Parent Initials*
Please select consent given below and sign.*

I give permission to have my child, named above, participate in all RodneyStreet programs/activities – this includes transporting child to/from activities, if necessary.I grant RodneyStreet unrestricted permission to use photographs and/or video and/or voice recordings taken of my child for use in RodneyStreet publications, including web sites or other electronic forms of media. I authorize RodneyStreet, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that RodneyStreet may use such photographs of my child, with or without my child’s name, and for any lawful purpose, including, but not limited to, publicity and Web content.I hereby release Rodney Street, its staff, contractors, and volunteers from any responsibility as a result of any injury to the child named above due to participation in Rodney Street activities.
Signature

Clear
Date

MonthDay Year
Date
Communications Consent
I understand that as part of the registration process, either one or both parent/guardians listed in this application will be automatically enrolled to receive RodneyStreet communications. This includes the Remind App (a text based service) that will be used by staff for program communications and emails that will include the RodneyStreet monthly newsletter and general organization informational emails. I agree to be enrolled unless I Opt-out below.

I do not wish to be enrolled in the Remind AppI do not wish to receive the RodneyStreet monthly newsletter