Connection Club Registration Form

Connection Club Registration
Student Information
Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Please share the reason(s) behind your decision to have your child participate? This information will remain confidential.
Please share any concerns you have regarding your child's behavior. This information will remain confidential.
Informed Consent and Acknowledgement

By signing below, I give permission for my child, as named above, to participate in The Connection Club organized by SCB Connection, Inc. While the program promotes social-emotional learning and conflict management, SCB Connection, Inc. makes no guarantees regarding the prevention of bullying.

Additionally, we are committed to creating a safe and supportive environment for all students participating in our The Connection Club. To foster open and honest discussions, we ensure that all information shared within our club meetings is treated with the utmost confidentiality. However, please be aware that any information shared by students may also be communicated to their parents or guardians to ensure their safety and well-being
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.

Connection Club Payment

USDPayment Amount in USD

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Connection Club Registration

Student Information

Payment Methods