Rise Up Summer Lab

Program Dates:

4-Day Program: June 10-August 2, 2025 (Monday-Thursday)

Times:

Session 1: 9:00 AM-12:00 PM

Session 2: 1:00 PM-4:00 PM L

ocation: Live Up Behavioral Health Location Ages: 5-13 years old Contact:

Email: harkessc@liveupbh.org

Phone: (419) 775-3835

Full Name

Age

Date of Birth*

Email

example@example.com

Gender

MaleFemalePrefer not to say

Any Allergies Food Medical etc

Any Medical Conditions or Special Needs

Social Security Number or Medicaid ID Number*

Parent/Guardian Full Name

Guardian Phone Number

Relationship to Child

Email Address

example@example.com

Emergency Contact Name & Phone (if different)

Program Preferences Program Option (select one):

Session Preference (select one): Session 1 (9:00 AM-12:00 PM) Session 2 (1:00 PM-4:00 PM) No Preference (assign based on availability) Does your child need any accommodations for sports or experiential activities? (e.g., physical limitations, sensory needs):

Session Preference

Session 1 9am-12pmSession 2 1pm-4pmNo Preference (assign based on availibility)

Does your child need any accommodations for sports or experiential activities eg physical limitations sensory needs

Photo/Video Consent: I give permission for my child to be photographed or recorded during program activities for promotional or documentation purposes by Live Up Behavioral Health.

Type a question

yesno

.

How did you hear about Rise Up Life Lab?

EmailSocial MediaFriend/Family Other: Text Message

Field Trip Permission: I give permission for my child to participate in offsite experiential trips. Transportation will be provided.

yesno

Liability Waiver: I understand that Live Up Behavioral Health will take all reasonable precautions to ensure my child's safety but is not liable for injuries or accidents during the program

YesNo

I Agree (required to participate) Behavioral & Therapeutic Support Consent: I consent to my child participating in individual therapeutic sessions with a licensed therapist and Qualified Behavioral Health Specialist (QBHS), as well as group SEL activities that includes a diagnostic assessment.

YesNo

Any additional comments or information we should know about your child

ParentGuardian Signature

MMDDYYYY

Families will receive a confirmation email or call within 3 business days of submission, confirming their session assignment and providing payment details (if applicable, though pricing isn't specified per guidelines

Rise Up Life Lab Registration Form