Student Application Form
After-School Program: 2023/2034
Student Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
2011
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1928
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1926
1925
1924
1923
1922
1921
1920
Year
Age
Gender
Grade in School 2023/24
Ethnicity
African American
Asian
Caucasian/White
Hispanic
Multi-race
Native American
Family Setting
Two Parents
Single Mother
Single Father
Grandparent
Foster
Other
Parent/Guardian (First point of contact)
First Name
Last Name
Gender
Relationship to Student
Home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email- used for all communication regarding student
example@example.com
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Actively Serving in the Military
Please Select
Yes
No
If Yes, Branch of the Military
Secondary Contact
First Name
Last Name
Relationship to student
Email
example@example.com
Same address as above? If no, please complete address below
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Additional Comments
Emergency Contact: Parents are always the first point of contact listed in order on this form. In the event of an emergency and we are unable to reach you, please list who you would like for us to contact.
First Name
Last Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
List Medical Concerns
Medical Insurance Company if parents cannot be reached
Physician's Name
Physician's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Please read and initial
I hereby certify that I am the legal guardian of the student listed on this application and approve my child’s application to the Avery C. Thompson Sr. Community Center (ACTCC). I understand that it is my responsibility to notify the Center of any changes that may affect my child’s application.
*
My child’s photo for publications on ACTCC website and social media can be used unless previous arrangements have been made.
*
I understand that my child must be picked up before the ACTCC closes, and that the Avery C. Thompson Sr. Community Center is not responsible for supervising students after the Center closes. A late fee may be enforced if a child is not picked up before closing time.
*
I understand that my child’s participation at ACTCC is based up his/her ability to obey the rules of ACTCC and their behavior toward the staff members and volunteers. Enrollment may be suspended or terminated at any time for misbehavior.
*
I agree to not hold ACTCC responsible in the event of an injury resulting from activities in or related to the Center and its programs. I give my consent for my child to be treated by a physician or hospital in the event of an emergency and for him/her to be transported to and from the necessary destination.
*
I hereby waive, release, free, indemnify, and agree to hold harmless the Avery C. Thompson Sr. Community Center, the Board of Directors, staff, organizers, sponsors, supervisors, participants and those transporting my child to/from activities relating to the Avery C. Thompson Sr. Community Center.
*
I understand that the ACTCC does not approve, or encourage Center volunteers to participate with youth members outside the control of professional staff.
*
I understand that the ACTCC and the School District will share academic information regarding my child’s education. The information will be used for determining the student/child’s current level of academic performance as well as the area of need for academic support. I may revoke this authorization at any time by notifying ACTCC in writing, however, it will not effect any actions taken before the revocation was received or actions taken on the previously shared information. This certifies that ACTCC can ask the School District for student/child’s current levels of academic performance as well as the academic support the student/child needs.
*
I give my permission for ACTCC to collect information via online or written surveys. questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results may be shared with ACTCC’s staff, funders, and other community stakeholders to provide evidence of program effectiveness and impact on our students.
*
I understand that ACTCC may share information about the minor child listed on this student application to evaluate program’s effectiveness. Information that will be disclosed to ACTCC may include the information provided on the student application, information provided by the minor’s School or School District and other information collected by ACTCC including data collected via surveys or questionnaires. All information collected by ACTCC will be kept confidential.
*
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