Clone of StrongHER Afterschool Program 2023-2024 Registration Form

Home/Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian/Caregiver Information 1

Name*

First NameLast Name

Best Contact Number*

Area CodePhone Number

E-mail*

Language spoken:*

Race/Ethnicity*

Choose all that apply:*

Emergency ContactAuthorized PickupLives with

Parent/Guardian/Caregiver Information 2

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

E-mail

example@example.com

Choose all that apply:

Emergency ContactAuthorized PickupLives with

Language spoken:

Race/Ethnicity

Additional Emergency Contact Information

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

Choose all that apply:

Authorized PickupNot Authorized to Pickup

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

Choose all that apply:

Authorized PickupNot Authorized to Pickup

Household Information-this information is gathered for grant purposes only and will be kept secure and confidential.

Household size:*

Annual Income:*

Consent for Internet Usage*

I give my permission for my child(ren) to access the internet for educational purposes under the supervision of program staff.I DO NOT give my permission for my child(ren) to access the internet for educational purposes.

Consent for Use of Photos, Video Recordings, work samples and projects*

I give my permission for use of my child(ren)'s photo, videos, work samples and projects and likenessI DO NOT give my permission for my child(ren) to access the internet for educational purposes.

Communication Agreement*

I agree to accept and respond to any communication methods provided by Staff to ensure that I am receiving information related to my child(ren) and the program. This includes text messages, phone calls, written correspondence, and emails.

Enrollment Agreement*

I understand that the Parental Consent is required for my child(ren) to participate in the Brite Project. I will attend the Parent and Caregiver Meeting on Thursday, April 25 at 7:00 PM EST to get final details about the project. The meeting will be via Zoom. The meeting link will be sent to parents prior to the meeting.

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.

Signature:

Registration Form-BRITE Program(Ages 13-16)