Elevate After School Program Registration

Elevate After School Program Registration
Elevate After School Program
Hosted by Empowering Young People at Hope Preparatory Academy

Start Date: September 2nd
Days/Time: Monday – Friday, 3:00 PM – 6:00 PM
Cost: $70 per student per week (1-month commitment; pay weekly or monthly)

The Elevate After School Program provides a safe, structured, and enriching environment for students. Each day begins at 3:00 PM with homework help and a snack. At 4:00 PM, students transition into their selected program — Media, Dance, or Physical Activity — led by dedicated instructors.

Pick-up: By 6:00 PM (late pick-up fees apply)
Student Information
Student's Name*

First NameLast Name
Birth Date*

MonthDayYear
School Name*
If you are not sure type N/A
Grade*
Gender*

MaleFemale
Additional Student(s)

Optional
Student Name #2

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Student Name #3

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional campers must show proof of living in the same household for a discount to be applied
Please write your student(s) name and the program number they would like to participate in:

Programs Offered:

1. Game Time Academy

with Corey Vereen – Elementary & Middle school students only

2. Dance, Cheer & Fun

with StarBound – Elementary & Middle School students only

3. Social Selling & Brand Building

with Ryan Adkins – Middle & High School students only

4. Media Writing, Sales & Search Stand Out

with Tanisha Adkins – Middle & High School students only

If you only have one student, just write the program number they would like to participate in.
Student(s) Name - Desired Program Number or Name*

Parent/Guardian Information
Parent Guardian Name #1*

First NameLast Name
Cell Number*
E-mail*
Weekly Camper Invoice will be sent to this email
Parent Guardian Name #2

First NameLast Name
Cell Number
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Name of additional Individual authorize to pick up your camper(s) besides you?
Contact's Name

First NameLast Name
Relationship
Phone Number
Please list any additional adults authorized to pick up your camper(s) | Please list their LEGAL first and last name

Does your camper have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Type N/A if they do not have any.
Does your camper have any chronic illness, or medical conditions? If yes, please describe.*
Type N/A if they do not have any.
Does your camper have any special needs and/or learning disabilities (Autism, ADHD, etc) ? If yes, please list all below.*
Type N/A if they do not have any.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Empowering Young People during the selected program. In exchange for the acceptance of said child’s candidacy by Empowering Young People. I assume all risk and hazards incidental to the conduct of the activities, and release, and hold harmless Empowering Young People and all its respective officers, agents, partners, coaches, teachers, instructors, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against Empowering Young People including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all physical activity. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named student(s), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Empowering Young People and its affiliates including volunteers, Hope International Church, and/or Hope Preparatory Academy Staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
By checking this box I acknowledge that I will pay camper fees according to schedule and whether your camper(s) attends one day or the whole week, the camper price is the same. No refunds
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.
Date*

MonthDayYear
Date
Signature*

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Payment Information
The first payment is due Friday, August 29th. Future payments will be due every Friday if you are paying weekly, or the last Friday of each month if you are paying monthly, to cover the upcoming period.eek.

If payment is not received by the due date, your student will not be able to attend the after-school program.

Please provide the email address where you would like invoices to be sent. We use Procare for billing and checking in/out, and processing fees will apply to all electronic payments.

If you prefer to avoid processing fees, you may pay in cash the Friday before the week of attendance when picking up your student(s).
Email to send invoice to:*
example@example.com
Payment Schedule Request*

I would like to pay WEEKLYI would like to pay MONTHLY
Should be Empty:

Elevate After School Program Registration

Student Information

Additional Student(s)