Innovation Boulevard Afterschool @ MCC Registration

INNOVATION BOULEVARD | Afterschool

Registration

at Mount Comfort Church

Produced by

The Diversity & Innovation Institute
Innovation Boulevard (iBlvd) is an Afterschool program provided by the Diversity & Innovation Institute (DNOVA).

Please Note: While this program is hosted at Mount Comfort Church, it is a secular program open to all students. We welcome children and families of all backgrounds, and the program is not affiliated with any particular religion.

To join, parents/guardians must complete this form. If you are registering more than one participant, please submit a separate form for each child. You may save your progress and return to this form at any time by clicking the button at the bottom of the page.

Participant's Information
Student's Legal Name*

First NameMiddle NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Email*
example@example.com
Student's Phone Number*
Please enter a valid phone number.
Student's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Grade*
If you are unclear about your student's grade, select the grade they will be entering in the fall
Elementary school*

Student Demographics

DNOVA values diversity and equity in STEM fields. To that end, we seek to ensure diversity in our programs. Collecting demographic data from our participants helps us evaluate our success in this objective. Responses will not affect entrance to the program.
Does the participant have a specialized Individual Education Plan?*

YesNo
Would you like to upload the participant's Individual Education Plan?*

YesNo
File Upload: Individual Education Plan*

Cancelof
Is the participant a Limited English Proficiency student?*

YesNo
Does the student participate in a free or reduced meal program?*

Yes, they receive free mealsYes, they receive reduced price mealsNo
Student's Gender*
Participant's ethnic background is best described as:*
Participant identifies their race as:*
Participant is under custody of*

Emergency Contact Information

We ask that you include one emergency contact with a different address
Emergency Contact Name*

First NameLast Name
Emergency Contact's Relationship to Student*
Emergency Contact's Phone Number*
Emergency Contact's Email
example@example.com
Emergency Contact's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Information
Does this student have any allergies or dietary considerations?*

YesNo
Allergies/Dietary Considerations*
Does this student have any present health conditions?*

YesNo
Present Health Conditions*
Does this student have any past health conditions/injuries that we should be aware of?*

YesNo
Past Health Conditions/Injuries*
Please list any medications the participant is currently taking. If none, write "N/A"*
Has this student received the COVID-19 vaccine?*

YesNoPrefer not to answer
Other information that would be relevant in the event of emergency medical treatment:

Insurance Information

Parents or legal guardians are responsible for the cost of a minor's medical treatment. When available, insurance information will be processed by the health facility performing the treatment; otherwise you will be contacted for payment by cash, check, or credit card.
Would you like us to provide insurance information for this student in the event of an emergency?*

YesNo, I'd like to be contacted directly about medical payments
Insurance Company
Policy Holder's Name
Policy Number
Member ID
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Relationship to Student*

Consent for Medical Treatment of a Minor
I, as the parent or legal guardian of the aforementioned Innovation Boulevard Participant, grant the following authorization for medical and/or surgical treatment of this minor by a health care professional should the need arise while they are attending the Innovation Boulevard program.
Please check and complete one (1) of the following:*

I grant permission to the directors, assistants, or other persons responsible for her/his care to act on my behalf for said minor in granting permission for evaluation and treatment of medical or psychological problems. I understand that should a major medical or psychological problem arise; reasonable attempts will be made to notify me by telephone. In the event that I cannot be reached, I give my consent to such medical treatment as deemed necessary, including surgery, x-ray examinations, and anesthesia to be rendered to said minor by a licensed physician or nurse.I do not wish medical care of any kind, except in case of an emergency.I authorize limited medical care specified below:
If authorizing limited medical care (checked above), please provide details of limited authorized medical care:*
Signature for Medical Care Authorization*

Clear
Date*

MonthDayYear
Date
I understand that Innovation Boulevard staff members are unable to administer medication. If a minor cannot self-medicate, a parent/guardian must come to the program to administer any required medications.

Consent and Release Form for Interviewing, Photographing and Videotaping

I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images”), and authorize the Diversity & Innovation Institute and companies with whom it collaborates (collectively, “DNOVA”) to use, release, publish, exhibit, post on the Internet, in CD-ROMs or any other medium any of my Personal Images, as described below and understand and acknowledge by signing this consent form the following:

By signing this form, I hereby give permission to DNOVA to use my Personal Images in whatever medium deemed appropriate by DNOVA for any of the following purposes: (i) public relations; (ii) marketing & social media; and (iii) training & education. DNOVA will not use the Personal Images for any other purposes.
- I understand that my Personal Images may be seen and used by DNOVA throughout the world and hereby give consent to such worldwide use for the purposes stated in this consent form.
- I understand that my consent is voluntary, that I am not required to sign this consent and that I may in fact refuse to sign it, thereby prohibiting DNOVA from obtaining or using any Personal Images of me.
- I have the right to revoke my consent at any time, which revocation must be in writing and submitted to DNOVA at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268; or via email at iblvd@dnova.org.
- I release and discharge DNOVA, its officers, agents and employees, and each and all persons involved in creating my Personal Images from any liability connected with the taking, recording, filming or publication of said interviews, photographs, slides, computer images, videotapes or voice recordings.
- I waive all rights I may have to claims for payment or royalties in connection with any exhibition, televising, internet posting, or other publication of my Personal Images, irrespective of whether a fee for its use is charged by any third party.
If I have any questions about my privacy rights under this form, I understand that I may contact DNOVA at 317-703-7836 or by writing at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268, or by emailing to iblvd@dnova.org.

If the subject of the personal images is under 18 years old, the parent or legal guardian must sign below.

By signing this Consent and Release Form, I consent to allow the minor named below to participate in the activities described above and allow the information obtained from the below named minor to be used and shared as described above. I represent and warrant that (i) I am eighteen (18) years of age or older and am legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the legal authority to represent the below named minor (iii) I have read and understand this Consent and Release Form and (iv) I have had an opportunity to ask questions about the use of the below named minor’s Personal Images, understand their purported use, knowingly consent to such use and voluntarily sign this Consent and Release Form on behalf of the below named minor.

You may request a copy of this Consent and Release Form by emailing iblvd@dnova.org.
Please select one:*

Yes, I have read and consent to the Consent and Release Form for Interviewing, Photographing, and Videotaping (United States). I give permission for my child to be interviewed, photographed, or recorded by DNOVA for approved uses.No, I do not consent to the Consent and Release Form for Interviewing, Photographing, and Videotaping (United States). I do not give permission for my child to be interviewed, photographed, or recorded by DNOVA.
Name of Minor*
Name of Parent/Guardian*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Innovation Boulevard at MCC Program Fees

Introductory Rates – Limited Time Offer! (Until December 31, 2025)

Days per week	Paid Weekly	Paid Monthly
5 days	$86/week	$340/month
4 days	$85/week	$320/month
3 days	$65/week	$260/month
1-2 days	$45/week	$180/month

Please Note:

Weekly payments must be submitted by Wednesday of the week before.
Monthly payments must be submitted by the 25th of the prior month

Additional Incentives:

$30 registration fee waived for all sign-ups before December 31, 2025
The first 40 participants to enroll will secure these discounted rates for the entire academic year—your rate will not increase

How to make payments:

To make a payment towards the Innovation Boulevard at MCC program at any time, please visit our website at dnova.org/iblvd-mcc. Once you select "Make a Payment", you will be directed to our secure payment portal. Instructions will also be provided via email.

How many days will your student attend? *
What frequency would you like to pay? *
5 Days Paid Weekly*
*This is the amount you will enter into the payment portal*
4 Days Paid Weekly*
*This is the amount you will enter into the payment portal*
3 Days Paid Weekly*
*This is the amount you will enter into the payment portal*
1-2 Days Paid Weekly*
*This is the amount you will enter into the payment portal*
5 Days Paid Monthly*
*This is the amount you will enter into the payment portal*
4 Days Paid Monthly*
*This is the amount you will enter into the payment portal*
3 Days Paid Monthly*
*This is the amount you will enter into the payment portal*
1-2 Days Paid Monthly*
*This is the amount you will enter into the payment portal*
Should be Empty:

INNOVATION BOULEVARD | Afterschool

Participant's Information

Student Demographics

Parent/Guardian Information

Program Information

Emergency Contact Information

Medical Information

Insurance Information

Consent for Medical Treatment of a Minor

Consent and Release Form for Interviewing, Photographing and Videotaping

Innovation Boulevard at MCC Program Fees