2026 6th Grade Summer Empowerment Program Application

2026 Summer Empowerment Program for Rising 6th Graders

REGISTRATION FORM: MUST BE COMPLETED BY A PARENT / GUARDIAN
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Best Contact Email
example@example.com
Student Biological Sex at Birth*
Student Gender (if different from above)
Preferred Pronouns
Student Race*
Student Ethnicity*
Elementary School Attended*
Middle School Attending This Fall*
Student Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name & Relationship to Student *(Add Row to add additional Parent/Guardians)*
Parent/Guardian Phone (Add Row to add additional Parent/Guardian Phone)*
Parent/Guardian Email (Add Row to add additional Parent/Guardians Email)
Preferred Contact Method
Household Size (Adults & Children)*
Annual Household Income (HH Size 2)*
Annual Household Income (HH Size 3)*
Annual Household Income (HH Size 4)*
Annual Household Income (HH Size 5)*
Annual Household Income (HH Size 6)*
Annual Household Income (HH Size 7)*
Annual Household Income (HH Size 8)*
My child receives free or reduced lunch.My child participates in special education or has an IEP.My child has RTI in place (response to intervention).My child has permission to attend field trips and off-site activities.My child has permission to walk home or take public transportation after the program.
Emergency Contact Name (If Different from Parent/Guardian)

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
My child will be picked up after the mentoring program by the following persons (please provide name, relationship, and cell phone number, adding each person on a separate row):
My child has the following food allergies:
YesNo
I certify that am the legal parent/guardian of the identified child name above and will provide proof upon request.
Parent / Guardian Signature*

Clear
Date*

MonthDayYear

PERMISSION TO PARTICIPATE:

My child has permission to participate in YEMBA, Inc. “Summer Empowerment Program” located at 218 Lake St. Oak Park, IL 60302. I understand that this program is free and that my child can participate without any cost to me for services or materials. I understand that the program is held at Julian Middle School, Monday through Thursday from 10:00am until 2:00pm. I understand that YEMBA does not provide transportation to and from program, unless otherwise specified. It is the parents’ responsibility to ensure their child has a way home after each session.

I understand that my child is responsible for his/her behavior and that all facility rules of conduct apply while participating in the Summer Empowerment Program (SEP). I also recognize that YEMBA reserves the right to deny service to children who do not follow the facility rules of appropriate behavior. Further, I indemnify and hold Y.E.M.B.A or Tennis and Fitness Centre harmless and blameless from any claim or incident occurring before or after the SEP. I further agree in case of injury or illness or other actions requiring parental permission, the staff shall have the authority to act for us in case we cannot be reached.
Parent / Guardian Signature*

Clear
Permission to Participate
Date*

MonthDayYear
Consent for Release of Information to the Community Mental Health Board of Oak Park Township:

I give my consent to Yemba to release my service records
to the Community Mental Health Board of Oak Park for audit-related purposes. This
information may be used only for the purpose of documenting and verifying the services
funded by the Community Mental Health Board of Oak Park Township. I understand the
requested or provided information is needed to determine eligibility for funded services. I
understand I have the right to see this information at any time, and that I can revoke this
consent in writing to both the person giving and the person receiving the information. Any
information already released may be used as stated on the consent. This consent is valid
only until one year from signature date. This consent is not automatically renewable. It expires
automatically at the end of the period specified unless revoked in writing sooner. By my
signature below, I affirm that I have read this release or it has been read to me, and that I
understand its content.
Signature

Clear
WAIVER & RELEASE OF LIABILITY:

In consideration of the risk of injury while participating in YEMBA Inc. activities, and as consideration for the right for my child to participate in the activities, I hereby, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my child’s participation in YEMBA, Inc. activities, and do hereby release and forever discharge YEMBA Inc., Tennis and Fitness Centre, Community Mental Health Board of Oak Park Township, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that my child may suffer as a direct result of participation in YEMBA Inc. activities, including traveling to and from any event related to these activities.

I agree to indemnify and hold harmless YEMBA Inc. against all claims, suits or actions of any kind whatsoever for liability, damages, or compensation brought by me or anyone on my behalf, including attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If YEMBA Inc. incurs any of these types of expenses, I agree to reimburse YEMBA Inc.

I acknowledge that YEMBA Inc. and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of YEMBA Inc.

In the event that any damage to equipment or facilities occurs as a result of my child’s actions, neglect or recklessness, I acknowledge and agree to be held liable for all costs associated with said actions.

I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified verbally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
Parent / Guardian Signature*

Clear
Waiver & Release of Liability
Date*

MonthDayYear
Should be Empty:

2026 Summer Empowerment Program for Rising 6th Graders