Asbury Park After-school / Squad Registration
Squad members learn circus techniques, life skills, and build trust with teens from other neighborhoods. They lead community engagement through workshops and performances for younger children and families. Squad is for ages 11-18. Join us after school on Tuesdays from 4:30-6:30 pm. Tuition is FREE. The Asbury Park Squad meets in the gym at Our Lady of Mount Carmel Catholic School, 1201 Asbury Ave, Asbury Park, NJ 07712.
Information of Parent/Guardian
Parent/Guardian Name
*
Parent First Name
Parent Last Name
Acct Record Type
Contact Record Type Participant
Household Name
Contact Record Type General
Full Name Parent
Parent/Guardian Gender
*
Male
Female
Nonbinary
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Relationship to Participant
*
Phone Number
*
Please enter a phone number.
Parent Email Address
*
example@example.com
Home Address
*
Street Address & Apt
Street Address Line 2
City
Please Select
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State
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Language Spoken at Home
*
English
Spanish
Other
Emergency Contact
Other than Parent/Guardian
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship to Participant
*
Emergency Contact Phone Number
*
Please enter a phone number.
Emergency Contact Email Address
*
example@example.com
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For funding purposes only
Are you head of household?
Yes
No
Are you 62 years of age or older
Yes
No
Are you disabled?
Yes
No
Race
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
Hispanic Ethnicity
Not Hispanic Ethnicity
Household Size
Type a number between 2 and 8
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Participant Registration
Name1
*
First Name1
Last Name1
Birth Date
*
-
Month
-
Day
Year
Date
Last Date of Year
-
Month
-
Day
Year
Date
Is the Partipant disabled?
*
Yes
No
Age1
Program1
Closing
Race
*
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
*
Hispanic Ethnicity
Not Hispanic Ethnicity
Gender
*
Female
Male
Nonbinary
Choose not to respond
Participant Cell Phone
Please enter a phone number.
Participant Email
example@example.com
School Name
*
Injuries/Illnesses/Medical Conditions/Current Medication
*
Accommodations Necessary for Participation
*
Please list any of the following: Medication allergies, food allergies, dietary restrictions or chronic health concerns.
Does Participant Have Health Insurance
Yes
No
Do you wish to register more participants?
*
Yes
No
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Additional Participant2
Name2
First Name2
Last Name2
Birth Date2
*
-
Month
-
Day
Year
Date
Age2
Participant Type2
Is the participant disabled?
Yes
No
Gender
Female
Male
Nonbinary
Choose not to respond
Race
Black/African American
Black/African American & White
Asian
Asian & White
Native Hawaiian/Pacific Islander
American Indian
American Indian & White
American Indian & Black/African American
White
Other Multi-Racial
Ethnicity
Hispanic Ethnicity
Not Hispanic Ethnicity
Participant Cell Phone
Please enter a valid phone number.
Participant Email
example@example.com
School Name
Injuries/Illnesses/Medical Conditions/Current Medication
Accommodations Necessary for Participation
Please list any of the following: Medication allergies, food allergies, dietary restrictions or chronic health concerns.
Does Participant Have Health Insurance?
Yes
No
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Permissions and Waivers
I hereby give permission for TCS staff to administer first aid as needed
In the event of an emergency when parent, guardian, and emergency contact cannot be reached, I hereby give permission to the medical personnel selected by TCS to administer emergency care.
I give permission for the image and voice of the participant to be used by the Trenton Circus Squad in any media for publicity.
I give permission for the participant to travel by car with the Trenton Circus Squad staff.
I give permission for the participant to leave Trenton Circus Squad unaccompanied.
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