Summer Program Registration Form

Summer Program Registration

This form is required for your child to attend Discovery Ed Programs
Youth Information
Youth Name *
Nickname
Birth Date *

Month Day Year
Gender *

Male Female N/A
Age
Registration FeePaid
First-Week Paid
NOTE - Registration is based on the grade the youth will be entering in the Fall of 2019.
Entering Grade in 2019/20 *
School Youth Attends *
Age-Group Registering For *
T-Shirt Size *
Program Location
Please list siblings that will also attend the Summer Program
Please provide any additional information that you think is important or may affect your child's ability to fully participate in the program.
Demographic Information

Many of our funding agencies request the following information on youth we serve. Information is kept strictly confidential. Your response is voluntary, however, this information contributes to funding granted to Discovery Ed for program support.
Youth Race

White Black/African American American Indian/Alaskan Native Native Hawaiian/Pacific Islander Asian
Youth Ethnicity

Hispanic/Latino Non-Hispanic/Latino
Household Profile

Single Parent Dual Parent
Household Monthly Gross Income

$0-$500 $501 - $1000 $1001 - $1500 $1501 - $2000 $2001 - $2500 $2501 - $4024 $4025+
Number in Household
Parent Information

Parent/Guardian 1
Parent/Guardian 1 *

First Name Last Name
Relationship to Child *
E-mail *
Home Phone *
Cell Phone
Work Phone

Residence Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mailing Address (if different)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Where would you like to be reached while your child is at Discovery Ed? *

Home Phone Cell Phone Work Phone
Parent Information

Parent/Guardian 2
Parent/Guardian 2

First Name Last Name
Relationship to Child
E-mail
example@example.com
Home Phone
Cell Phone
Work Phone
Address Same as Parent/Guardian 1?

Yes

Residence Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mailing Address (if different)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Where would you like to be reached while your child is at Discovery Ed?

Home Phone Cell Phone Work Phone
Emergency Contacts

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact 1
Full Name *

First Name Last Name
Primary Phone Number *
Secondary Phone Number
Relationship to Child *
Emergency Contact 2
Full Name

First Name Last Name
Primary Phone Number
Secondary Phone Number
Relationship to Child
Authorized Pick-Ups

Authorized Pick-ups are in addition to Parent/Guardian and Emergency Contacts.
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Prohibited Contacts

Anyone PROHIBITED from contacting or checking-out the youth.
Name
Name

Permission Slips, Agreement & Disclaimer
Video & Photograph Permission
I authorize Discovery Ed to produce videos and photographs of my child. This authorization is given on the condition that the materials taken or produced will be used for the purpose of community education or program promotion. I understand that Discovery Ed and its employees will not use these materials for compensation. I understand that this grant of permission shall only be revoked by delivering a written statement to Discovery Ed. This consent shall remain in effect, unless revoked.
Type first and last name above to consent
I decline to authorize videos and photographs of my child.
Type first and last name above to consent
Field Trip Permission
I give permission for my child to accompany Discovery Ed program staff to various designations/field trips. Field trips include trips to other businesses and parks. I will be notified of all field trips and mode of transportation. *
Type first and last name above to consent
Waiver, Release, Indemnification & Hold Harmless Agreement
I hereby agree to waive, release, absolve, indemnify and agree to hold harmless Discovery Ed, its directors, officers, board members, volunteers, sponsors, staff and participants for, from and against all liability because of any bodily injury, or property damage, known or unknown, which may occur or result from participation of the above named child in any and all activities whether the result of alleged negligence or for any other cause of Discovery Ed. I certify that I am familiar with the content of this release and that I have read and understand the same and that it is my intention by signing this release, that the same be binding not only upon me, but also upon my heirs, administrators, executors, successors and/or assigns. By signing below I agree to the above statements. *
Type first and last name above to consent
Drop-In Policy
Discovery Ed has a Drop-In Policy, meaning that youth must sign in and out of the center each day. Youth are allowed to leave the center whenever they choose. If you would like your child to remain at the center at all times, please instruct them not to leave. If your child does choose to leave the center, please instruct them who they can leave with. Discovery Ed is not responsible for youth once they sign out. Discovery Ed has a safety policy for youth under the age of 12. Youth under the age of 12 must be picked up from the center by a parent, guardian or another authorized individual. *
Type first and last name above to consent

Summer Program Registration

Youth Information

Demographic Information

Parent Information

Parent Information

Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Authorized Pick-Ups

Prohibited Contacts

Medical / Health Information

Permission Slips, Agreement & Disclaimer

This is to help us plan for the growth of the program and does not affect admittance of your student to the program.

Fee and Payment Guidelines