2026-27 Afterschool Program Registration and Waiver Form

2026-2027 Afterschool Program

First Day for students: September 21st (Monday)

The Center is open

Monday-Thursday

2:30-6:00 *New Time*

2100 W. High Street Racine *New Location*

We follow the RUSD calendar for days off

Services are Free but donations are accepted

Donate Here

We provide services to students in 4th-12th grade who attend Racine public or private schools

Name of the Child

First NameLast Name

Birthdate

Date

Current Age of Child

Grade Attending in 2026-27

Grade number; example: 4

School Attending in 2026-27

Name of School

Gender

Select One

Name of the Parent/Guardian

First NameLast Name

Relationship to Student

Parent/Guardian's Phone Number

Format: (000) 000-0000.

Parent Email

example@example.com

Student Pickup and Sign-Out Procedures

For the safety of our students and to provide clarity for Center staff, we must have a current photo on file for every individual authorized to pick up a student. This includes parents/guardians, alternate pickup individuals, and emergency contacts who may be authorized to pick up a student.

Photos may be taken by Center staff or emailed to Julie_kamphaus@john23center.org.

When picking up a student, the authorized individual must sign the student out before leaving the Center. These procedures help ensure that every student is released safely and that our staff can clearly identify each person authorized to pick them up.

My child has permission to go home with: (John 23 must be notified)

First NameLast Name

My child has permission to go home with: (John 23 must be notified)

First NameLast Name

Emergency Contact Name (other than the parent)

Emergency Contact Phone number (other than the parent)

Format: (000) 000-0000.

Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies/Food Allergies? List, but if there are not any, say None.

Medical Conditions? List, but if there are not any, say None.

Do those medical conditions require medicine? (Example: epipen or inhaler) List, but if there are not any, say None.

Do you Qualify for Free or Reduced Lunch through your child's school?

Race/Ethnicity

I give permission for my child to use technology

I give permission for John 23 Ed. Ctr. to use test assessments with my child in Math & Reading

I consent that any still or electronic image and/or audio recording in which my child may appear may be used by John 23 Ed. Ctr. and/or by the Archdiocese of Milwaukee. I understand that these materials are being used for promotion of John 23 Educational Center and/or the Archdiocese of Milwaukee. These images and/or recordings may be used to support recruitment, fundraising, evangelization and other communication efforts. I release the staff and volunteers and I understand and agree that the use of my picture is not an invasion of privacy. Neither I, nor anyone claiming to be speaking on my behalf, will later object to the Archdiocese's use of this/these photographs.

Statement of Consent & Waiver

I hereby agree and declare that I am the legal parent or guardian of the above-named child and hereby consent to the child's participation in the activities that are described to me in registration process.

Emergency Medical Treatment: In the event of an emergency, 911 will be contacted by a staff member followed immediately by a contact with parents/guardian or the person you have indicated as an emergency contact. If the 911 medical team recommends transportation to the hospital immediately, I hereby give my permission to transport my child to Ascension All Saint’s Hospital 3801 Spring St, Racine, WI 53405 for emergency medical treatment. I understand that I am responsible for any medical costs incurred.

My child and I have both read and agree to follow the Contract of Understanding.

By registering for this program, I agree to these guidelines.

Please review the Technology Use & Care Contract with your student. Hard copies can be requested at julie_kamphaus@john23center.org

Please review the Contract of Understanding with your student. Hard copies can be requested at julie_kampahus@john23center.org

Parent/Guardian Signature *All information provided is true. There is an understanding of the Technology Agreement, Contract of Understanding & Photo/video statement

After School Program Registration and Waiver Form