Grounded Minds Registration Form
Student Information
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade
*
School Currently Attending
*
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Parent/Guardian Information
Name
*
First Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact (other than parent/guardian)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Continue
Continue
Medical Info
Physician Name
First Name
Last Name
Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Provider
Policy Number
Name of Policy Holder
First Name
Last Name
Allergies (food/medicine/environmental)
*
Medical Conditions / Medications
*
Mental Health Needs or Disabilities we should be aware of.
*
I authorize Grounded CSK staff to seek emergency medical care for my child if I cannot be reached.
*
Yes
No
Signature
*
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Enrichment Selection
6pm-7pm Time Block
Select the program you want your child enrolled in. All enrichment programs are optional.
*
Monday (Middle School Life Skills / High School Art)
Tuesday (High School Life Skills / Middle School Art)
Wednesday (Game Day)
Thursday (Islamic Studies)
None of the above
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Authorized Pick-Up
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
My child may walk home alone.
*
Yes
No
Signature
*
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Waivers & Agreements
I release Grounded CSK, its staff, and volunteers from liability for ordinary risks of participation.
*
I authorize staff to administer basic first aid and seek emergency medical care if needed.
*
I give permission for photos/videos of my child to be used in promotional materials.
I understand my child is expected to respect staff, peers, and program rules. Disruptive behavior may result in suspension or removal.
*
I agree not to send my child if sick and to inform staff of allergies or conditions.
*
I give permission for my child to participate in off-site activities.(Additional details will be provided before each trip.)
*
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Payment & Scholarship Selection
Grounded CSK’s After-School Youth Program is sustained through a suggested monthly contribution of $150 per student. To ensure that every child has access, we also offer a no-questions-asked scholarship option. Please select the option that best fits your family:
*
I will contribute $150/month via the donation portal.
I request a full scholarship at this time.
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