2027 After-School Registration Form

Rise & Reign After-School Program Registration Form

Please fill out your details to register for the program. If you have more than one child enrolled, please complete separate forms for each child.
Student's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade
Select student grade for the upcoming school year
T-Shirt Size
Do you need financial assistance?
If yes, please briefly explain your need
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student Allergy and Medication Information

Please provide the allergy and medication details of your student(s) to ensure proper care.
Upload a photo of your student

Please upload a clear, recent passport-style photo of your student. The student's face should be fully visible, well-lit, and facing the camera with a simple background and no filters.
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List any food allergies your child has
List any other allergies your child has
Please list all medications the student currently takes (include dosage and frequency)
Does the student require medication to be administered at school?
Preferred Hospital
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional notes or special instructions
Medication & Emergency Treatment Consent

I understand that Rise & Reign Summer Program staff may need to support my child in the event of illness, injury, or a medical need during camp hours.

I give permission for staff to:
- Administer the medications I have listed on this form, as needed and according to the instructions I provide.
- Provide basic first aid if my child becomes injured or ill.
- Seek emergency medical care for my child if I cannot be reached, including transportation by EMS and treatment by medical professionals.
I understand that I am responsible for providing medications in their original containers and for any medical expenses that may result from emergency treatment.
Consent:
Signature
Should be Empty:

Rise & Reign After-School Program Registration Form

Student Allergy and Medication Information