Project R.O.C.K. South Inc. Enrollment Application

Project R.O.C.K. South Inc. Enrollment Application
Student Name*

First NameMILast Name
Date of Birth*

MonthDayYear
Age*
Age
MaleFemale
Race*
Ethnicity*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Person Enrolling Student*

First NameLast Name
Relationship to Student*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Type*
Pickup Individuals

Please provide information for up to two individuals authorized to pick up the student.
Pickup Person 1 Name*

First NameLast Name
Pickup Person 1 Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student*
Pickup Person 2 Name

First NameLast Name
Pickup Person 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student
How will the student arrive?*
How will the student depart?*
Additional Comments (optional)

School*
Grade*
Reason for Suspension (Offense)*
Length of Suspension (Days)*
Student ID#*
Student Lunch Number*
YesNo
YesNo
YesNo
Please Upload Suspension Letter or Referral Notice from School

Cancelof
YesNo

Medical Information
I, First & Last Name* (legal guardian) authorize medical transportation in the event of an emergency.
SeizuresAllergies
YesNo
Please list any medication the student is required to take during program hours:
Please include medication name, dosage, and time to be taken
Please Note:
Project R.O.C.K. South Inc. staff are not responsible for administering medication to students. Parents/guardians must make appropriate arrangements if medication is required during program hours.
I hereby authorize the St. Lucie School Board to release the medical recorde to Project R.O.C.K South, Inc. for the following student:

Student First NameStudent Last Name
Parent/Guardian Signature
Date*

MonthDayYear
Workshops/Seminars

As part of the Project R.O.C.K. South, Inc. program, we collaborate with other community agencies that visit our site and host an interactive Workshops/Seminars with the students. The students are engaged in a variety of discussion topics, such as: Conflict Resolution, Bullying, Self-Esteem, Peer Pressure, HIV & STDs, Drugs, Violence, & Anger Management.
I WOULD like my child to participate in the Workshops/Seminar.I WOULD NOT like my child to participate in the Workshops/Seminar.
Please note that some topics may be restricted based on student age or grade level.

Program Agreement

Agreement Between PROJECT R.O.C.K. SOUTH INC. and STUDENT, PARENT, OR LEGAL GUARDIAN
Please read the 11 statements below:
1. Any suspended student from grades K-12 of St. Lucie County is eligible to attend Project R.O.C.K. South Inc.
2. The student will not be allowed to leave until the end of the program day unless otherwise noted by the parent or legal guardian.
3. Parents or legal guardians will not hold Project R.O.C.K South Inc. or Children's Services Council of St. Lucie County and its staff or directors liable for any injuries that may occur while attending Project R.O.C.K. South program. Any medical needs occurring while in the care of Project R.O.C.K South is the student, parent, and legal guardian's sole responsibility.
4. No student can be removed from the program except by authorized persons noted on the enrollment application. (I.D. Required).
5. Students must be signed in by parent(s), obtain necessary materials, be seated, and be prepared to follow instructions from staff, mentors, and tutors.
6. All food and beverages are to be consumed only in the designated area(s).
7. Under no circumstances will students be allowed to engage in excessive talking, fighting, arguing, or disrespectful behavior that violates the rights of others.
8. Strictly NO smoking, vaping, drugs, weapons, inappropriate articles, images or equipment, profanity, abusive or insulting language allowed on campus.
9. Students must maintain a respectful attitude while participating in the program.
10. Students may have a talk session anytime with a Project R.O.C.K. South director or staff member(s).
11. Project R.O.C.K. South is funded by the Children's Services of St. Lucie County (C.S.C.). I understand that general information about each student's attendance and program outcomes is required to be reported to C.S.C. quarterly
I have read the agreement; I understand and agree to abide by the 11 statements.*
Parent/Guardian Initials

Liability & Hold Harmless Release
I,First & Last Name, FOREVER RELEASE Project R.O.C.K. South Inc. and Children's Services Council of St. Lucie County, staff and volunteers, all members of the board, officers and directors, harmless from any actions, claims, or demands that I, my next of kin, spouse, and legal representatives now have, or may have in the future, death, or property damage, related to (I) my child's participation in these activities, (II) the negligence or other acts, whether directly connected to these activities or not, however, caused, by and release or (III) the condition of the premises where these activities occur, whether or not I am then participating in the activities. I also agree that I, my next of kin, my spouse, and legal representatives will not make a claim against, sue, or attack the property of any release concerning any of the matters covered by the foregoing release.
I have read the liability release; I understand and agree to the conditions stated
Parent/Guardian Initials
Signature
Date*

MonthDayYear

Photo/Video Release & Consent
As part of the Project R.O.C.K. South Inc. program, we occasionally take photographs or videos of students engaged in program activities, such as academic work, workshops, and structured learning.

These images may be used to:
- Share program updates with partners
- Highlight student engagement and achievements
- Include in reports to funders
- Support educational or promotional materials (brochures, website, social media, etc.)
We are committed to using images respectfully, responsibly, and appropriately.
YES, I GIVE permission for my child’s photo/video to be used as described aboveNO, I DO NOT GIVE permission for my child’s photo/video to be used
Signature*
Date*

MonthDayYear

I certify that the previous information provided is accurate and complete to the best of my knowledge.*
Parent/Guardian First & Last Name
Should be Empty:

Project R.O.C.K. South Inc. Enrollment Application

Pickup Individuals

Medical Information

Workshops/Seminars

Program Agreement

Liability & Hold Harmless Release

Photo/Video Release & Consent