South County Back to School Community Day
Thank you for registering for the South County Back to School Community Day, hosted by Stars In Motion Inc. in partnership with Bay Community Health. This free community event will include backpacks and school supplies, health screenings, sports physicals, youth activities, community resources, and more. Registration helps us plan for attendance, parking, supplies, and health services. Backpacks, physicals, screenings, haircuts, and giveaways may be limited and are available while supplies or appointment slots last. **Children must be present to receive backpacks and school supplies.**
Parent / Guardian Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Demographic Information: This information is optional and will only be used in aggregate to help us understand who we are reaching and improve future programs.
*
Black / African American
White
Asian
Native American
Hispanic
Prefer not to answer
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
*
Text
Email
Phone
Select your preferred arrival window( If your preferred window fills, we may contact you to offer the closest available arrival time.) To help us manage parking, check-in, backpacks, health services, and activities, families are asked to arrive during their selected time window. You are welcome to stay and enjoy the event after checking in.
*
10:00 AM –10:30 AM
10:30 AM –11:00 AM
11:00 AM –11:30 AM
11:30 AM–12:00 PM
12:00 PM–12:30 PM
12:30 PM –1:00 PM
1:00 PM–1:30 PM
1:30 PM –2:00 PM
Does your child currently have health insurance?
*
Yes
No
Not Sure
No, but I would like information about applying
Community
What community do you live in ?
*
Please Select
Shady Side
Deale
Lothian
Galesville
Churchton
Edgewater
Harwood
Davidsonville
Mayo
other
Student Information
Please complete one form per household. You will be able to list each child who will attend
Name
*
First Name
Last Name
Age
*
School Attending
*
Grade entering
*
T-Shirt Size
*
Demographic Information
*
Black / African American
White
Asian
Native American
Pacific Islander
Prefer not to answer
Do you have another child who will be attending?
Please Select
Yes
No
Name
*
First Name
Last Name
Age
*
School Attending
*
Grade entering
*
T-Shirt Size
*
Demographic Information
*
Black / African American
White
Asian
Native American
Pacific Islander
Prefer not to answer
Do you have another child who will be attending?
Please Select
Yes
No
Name
*
First Name
Last Name
Age
*
School Attending
*
Grade entering
*
T-Shirt Size
*
Demographic Information
*
Black / African American
White
Asian
Native American
Pacific Islander
Prefer not to answer
Do you have another child who will be attending?
Please Select
Yes
No
Name
*
First Name
Last Name
Age
*
School Attending
*
Grade entering
*
T-Shirt Size
*
Demographic Information
*
Black / African American
White
Asian
Native American
Pacific Islander
Prefer not to answer
Do you have another child who will be attending?
Please Select
Yes
No
Name
*
First Name
Last Name
Age
*
School Attending
*
Grade entering
*
T-Shirt Size
*
Demographic Information
*
Black / African American
White
Asian
Native American
Pacific Islander
Prefer not to answer
Which services or activities are you interested in at the event?
*
Backpack/school supplies
Sports physical
Health Screenings
Haircuts/hairstyles
Kids Zone
Community vendors
Giveaways
I understand that if I request a sports physical or other health services, my contact information may be shared with Bay Community Health so they can contact me before or after the event regarding appointments and services.
*
I Agree
What resources would benefit your family beyond this event?
*
Health screening
Dental resources
Vision resources
Mental health resources
Food/nutrition resources
Narcan training
Drug use workshop
Tutoring
Mentoring
After- school programs
College / Career Readiness
Youth Sports
How did you hear about this event?
*
Facebook
Instagram
School
Bay Community Health
Friend
Church
Flyer
Other
Would you like to receive updates about future programs?
*
Yes
No
Media Release
I authorize Stars In Motion to photograph/video my family during the event.
*
Yes
No
Liability Waiver
Signature
*
Children Information
Submit
Submit
Should be Empty: