Summer Enrichment Program Registration

Summer Enrichment Program

Gateway to Transformation
Child's Information
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Entering Grade
Child must be entering 3-5 grade to be eligible
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Please select the block your child is registering for ($100 per block + $25 Registration Fee)
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Emergency Contact #2 Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your child prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by TOP Community Development during the selected camp. In exchange for the acceptance of said child’s candidacy by TOP Community Development, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless TOP Community Development 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 TOP Community Development including all leaders, teachers, volunteers, and all participants, sponsoring agencies, advertisers.
Confirmation

BY ACKNOWLEDGING AND SIGNING 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.
Date

MonthDayYear
Date
Signature

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Photo Release Form
Dear Parent/Guardian:

During the After School Care Program and Summer Enrichment, we take photographs of school activities involving students to share the school's positive vibe and updates. By which incidentally, some photographs may capture your child's participation, directly or indirectly.

These photos may be published through our website, social media pages, news bulletins, billboards, and ads.

With this, we seek for your consent in allowing us to publish photos which may involve your child to the said platforms.

Please do provide your response by selecting your choice below and submitting this form:
Child's Name

First NameLast Name
Parent's Name

First NameLast Name
Please opt in/out below:

I hereby allow the reproduction and publication of my child's photograph(s)I do not allow the reproduction and publication of my child's photograph(s)
Signature

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Date

MonthDayYear
Date

Policy Agreement Form

Bullying Policy
Type a question

I have read and understand the TOP Community Development Bullying policy terms included in the Parent's Handbook.I have discussed Bullying/cyberbullying with my child(renI have read this whole document and I accept the terms indicated above.
Signature

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Date

MonthDayYear
Date
Parent's Name

First NameLast Name
Date Giving Consent

MonthDayYear
Date
Terms & Conditions

Medication must be in the original named box/bottle and always labeled with the child’s name, DOB, dose, and date. (dispensed from the pharmacy). Please supply a measured medicine cup/spoon/syringe. Please give staff all the information required to ensure the child's well-being. At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions. All forms should have clear and specific Reasons, Signs & Symptoms
Agreement to the Terms & Conditions

I agree to the terms and conditions above

Medication Administration Form

For TOP Community Development Staff to administer PRESCRIBED medication
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Medication Name (as it appears on the label)
Dosage to be Administered
Time to administer the dosage

Hour Minutes

AM/PM Option
Reason for the medication
Should be Empty:

Summer Enrichment Program

Child's Information

Photo Release Form

Policy Agreement Form

Medication Administration Form