Summer Spark Program Registration and Waiver Form

This year we have designed a summer program where students can learn while having fun and develop their skills!

Program Details:

Location: Sacred Heart Catholic Church 2201 Northwestern Ave. Racine

Days/Times: Tuesday's & Wednesday's 4:00-6:00

Program start/end: June 10th-August 20th

Questions, contact: Katie Harms Katie_Harms@john23center.org

Name of the Child*

First NameLast Name

Birthdate*

Date

Grade Attending in Fall of 2025*

School Attending in Fall of 2025*

Gender*

Name of the Parent/Guardian*

First NameLast Name

Relationship to Student*

Parent/Guardian's Phone Number*

Emergency Contact Name (other than the parent)*

Emergency Contact (other than the parent)*

Parent Email*

example@example.com

Parent/Guardian's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies/Food Allergies? List, but if there are not any, say None. *

Do you Qualify for Free or Reduced Lunch?*

Race/Ethnicity*

I give permission for my child to use technology*

I give permission for John 23 Ed. Ctr. to use test assessments with my child in Math & Reading*

I consent that any still or electronic image and/or audio recording in which my child may appear may be used by John 23 Ed. Ctr. and/or by the Archdiocese of Milwaukee. I understand that these materials are being used for promotion of John 23 Educational Center and/or the Archdiocese of Milwaukee. These images and/or recordings may be used to support recruitment, fundraising, evangelization and other communication efforts. I release the staff and volunteers and I understand and agree that the use of my picture is not an invasion of privacy. Neither I, nor anyone claiming to be speaking on my behalf, will later object to the Archdiocese's use of this/these photographs. *

Statement of Consent & Waiver

I hereby agree and declare that I am the legal parent or guardian of the above-named child and hereby consent to the child's participation in the activities that are described to me in registration process.

Emergency Medical Treatment: In the event of an emergency, 911 will be contacted by a staff member followed immediately by a contact with parents/guardian or the person you have indicated as an emergency contact. If the 911 medical team recommends transportation to the hospital immediately, I hereby give my permission to transport my child to Ascension All Saint’s Hospital 3801 Spring St, Racine, WI 53405 for emergency medical treatment. I understand that I am responsible for any medical costs incurred.

My child and I have both read and agree to follow the Contract of Understanding.

By registering for this program, I agree to these guidelines.

Please review the Contract of Understanding with your student.

Parent/Guardian Signature*