STEAMS: Summer Program Application

STEAMS SUMMER PROGRAM APPLICATION & CONSENT FORM

Smoketown Teen Empowerment and Mentoring Support (STEAMS), is a dynamic initiative dedicated to empowering the teens of Meyzeek Middle School in the vibrant Smoketown area. It is a program of Blueprint502.
Student Full Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Student Grade (Current Grade Level)
Health Information
Does your student have any allergies? If yes, please list and explain.
Does your student take any medications during camp hours? Provide medication names, dosage, frequency and any special considerations.
Does your student have any medical conditions we should be aware of?
Does your student have any behavioral or support needs we should know about to help them be successful in camp?
Is your student allowed to participate in physical activities?
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to Student
Mother, Father, Aunt, etc.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
A copy of this application will be sent to this email.
Emergency Contact Name (if different from parent/guardian)

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attendance and Participation
How will your student get home after camp each day?

Other
Releases
CODE OF CONDUCT:I understand that my child is expected to adhere to the program's code of conduct, which includes respectful and responsible behavior. Any violation of the code of conduct may result in the participant being removed from the program.
Do you give permission for your student to be transported using Blueprint502 transportation when applicable (including field trips and program-related travel)?
MEDICATION/ EMERGENCY MEDICAL TREATMENT RELEASE: If my child requires medication during the program, I will provide detailed instructions to the program staff, including dosage, frequency, and any special considerations. In the event that I, or the emergency contact listed, cannot be reached in the case of a medical emergency, I authorize the program staff to seek medical treatment for my child.
MEDIA RELEASE: Photos/ Videos are taken of the program throughout the year and may include your child directly or indirectly. These photos/ videos may be published through our website, social media, news bulletins, advertising and other media. Please indicate your consent and release of your child's image/ likeness to be used without notice and additional permission.
PARTICIPATION RELEASE: As the parent/guardian, I hereby give consent for my child, to participate in the STEAMS Summer Program organized by Blueprint502. I understand that the program will take place at the Smoketown Community Center and may include planned field trips for participants. Assumption of Risk and Release of Liability: I acknowledge that participation in the program involves inherent risks, including, but not limited to, physical injury and exposure to new environments. I release STEAMS/ BLUEPRINT502, its staff, and volunteers from any liability arising from my child's participation.
Parent/ Guardian Full Name
Date

MonthDayYear
Date
Should be Empty:

STEAMS SUMMER PROGRAM APPLICATION & CONSENT FORM

Health Information

Parent/Guardian Information

Attendance and Participation

Releases