Work schedule changing? New job? Need a safe and nurturing environment for your child(ren) after school?

Merrick House is pleased to offer our After School Program for those families who need care for their children beyond the normal school day. We are now enrolling for Back to School and spots are filling fast. The first 10 families who enroll by September 1st, will receive a $10 VISA giftcard! You don't want to miss this amazing opportunity, so get your enrollments in today and please feel free to pass on the word to your friends and family about our Merrick House Youth Program.

Please complete and submit one form per student being enrolled in the After School Program.

*Youth Members must currently be enrolled in school in order to participate in youth programs.

I, the parent/legal guardian of the minor youth member listed on this application, for ourselves, our heirs, executors, administrators, hereby release, acquit, waive, and forever discharge Merrick House (Merrick House Neighborhood Center), their insurers, representatives, successors, assigned person/organizations, and any other entity or person associated with the Merrick House - such as staff, partner programs, volunteeers, or other official affiliates, from all liability, claims, demands, or causes of action for any and all loss, damage, injury, or death and claim of damages resulting from the use of facilities owned or controlled by Merrick House, or participation in activities of said organizations either at or away from said facilities, I also agree to the following:

Medical Emergency

I give permission to Merrick House to seek emergency medical treatment for the minor child listed on this youth member intake form if I cannot first be reached by phone. I will be responsible for any and all costs of medical attention, emergency transportation and treatment. I will not hold Merrick House, or any person associated with them, responsible for any medical claim arising from such treatment/medical attention. 

Travel Miscellaneous

I will not hold Merrick House, or any other person associated with them, responsible for any injury or death that may result from accidents or misfortunes while traveling to or from Merrick House or Merrick House sponsored events and programs. Additionally, Merrick House is not responsible for lost or stolen items or devices youth members bring to our facilities, events or programs. We will however, do our best to place lost items in a designated place for a designated time for claim, but we cannot guarantee the condition of any outside items or devices.

School Information

I give permission to Merrick House and the school district of the minor youth member on this application to exchange information such as test scores, school attendance, IEP/504 Plans and other information regarding the youth member. The purpose of this exchange is to better equip the student for academic success at Merrick House, and life in general. This information also helps Merrick House staff and partner programs better serve your youth member.

Statement of Policy

• An Enrollement Form is required for all students participating in this program.
• The After School Progrm ends promptly at 6:00 p.m.
• Ages 6-17 students can start program promptly at 3:00 p.m. and  participate supervised programs such as sports, tutoring, clubs, and more.
• Students may participate on a drop-in basis with prior notification from parents. If no Enrollment Form has been previously submitted, you will be sent an email with the link to this form to complete and submit.
• Only persons authorized by the parent or guardian may pick up your child from the After School program. Please notify the Director in writing if anyone other than a parent/guardian will pick up your child.

• All students attending the After School Program are required to follow all school and program rules. Behavioral problems will result in parent notification and possible suspension from the program.
• Students with a fever or contagious illness may not participate in the program.
• Fall semester After School Program runs from September 25, 2023 – December 15, 2023.
• Spring semester After School Program runs from January 2, 2024 – May 29, 2024.

I (Legal Parent/Guardian) _________________________hereby grant the Merrick House and/or its partners/affiliates permission to use (Child's Name Here) ________________________likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of Merrick House and/or its partners/affiliates will not be returned.

I hereby irrevocably authorize Merrick House and/or its partners/affiliates to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my child's likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge Merrick House and/or its partners/affiliates from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of ym estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT: