PROPEL P.L.A.Y. Summer 2026 Student Registration Form
JUNE 29th through JULY 31st
We are excited to provide students with a summer full of connection, creativity, leadership, movement and fun. Our goal is to create a safe and engaging environment where students can build friendships, explore new experiences and continue growing all summer long.
Program Hours: June 29th thru July 31st | Monday-Friday | 9:00AM - 5:00PM
Meals Provided: Breakfast and lunch are included daily.
Transportation: Selective transportation available *
Please coordinate directly with Drew for transportation arrangements.
Please complete the registration form below for each student attending.
STUDENT Information: (please print clearly)
Name
*
First Name
Last Name
Gender:
*
Male
Female
Race:
*
Black/African
American Hispanic
White
Multi-Racial
Other
Other:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth (mm/dd/yyyy):
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Student Cell Phone:
*
Format: (000) 000-0000.
Student Email:
*
example@example.com
School entering in the Fall:
*
Grade entering in the Fall:
*
How did you hear about PROPEL:
School
Church
Web
Friend
Other:
First Time PROPELIAN:
YES
TRANSPORTATION: * Transportation is not guaranteed, please coordinate with Drew.
*
Need Morning Pickup:
Need Afternoon Drop-Off:
Transportation NOT NEEDED:
PERMISSION TO WALK/BIKE TO and/or FROM PROPEL PLAY PROGRAM:
*
YES
NO
What is one thing your student wants to accomplish this summer or anything additional you want us to know - favorite sport / hobby / talent?
Back
Next
Parent/Guardian Information: (please print clearly)
Parent/Guardian 1 Name
*
First Name
Last Name
Relationship:
*
Cell Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
Parent/Guardian 2 Name
First Name
Last Name
Relationship:
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact: (if different from persons listed above)
Emergency Contact Name
First Name
Last Name
Relationship:
Cell Phone:
Format: (000) 000-0000.
Email:
example@example.com
MEDICAL & EMERGENCY INFORMATION:
Please note that we are unable to administer or hold medications for your child as we do not have a nurse on site. Therefore, if medication (Epi-Pens, inhalers, etc) is needed your child must keep it in their bag and be able to administer it properly to themselves.
Does your child have any allergies?
*
Yes
No
If Yes, please list allergies (ex.. bees, peanuts, dairy):
*
Does your child have an EpiPen?
*
Yes
No
Does your child take medication during program hours?:
*
Yes
NO
If Yes, please list medications:
Medical Authorization:
In the event of a medical emergency, I authorize PROPEL staff to secure emergency medical treatment for my child if I cannot be reached immediately.
*
YES
NO
Any activity the student should be restricted from?
Back
Next
VAN TRANSPORTATION POLICY:
Transportation is provided for students in vans clearly marked with the PROPEL logo and colors. PROPEL students will be picked up from the designated pickup area at their school, at a specified time, and driven to the PROPEL facility. We expect your child to be on their best behavior while in our vans. They must sit down, talk quietly and follow the driver's directions. Failure to do so may result in suspension from the van, which will be given at the driver or staffs discretion. Should a member receive a suspension, that member will lose the right to ride in the van for a period of time. Van suspensions will be determined by the PROPEL staff. PROPEL will provide students with a ride home (with-in our radius) at the close of PROPEL programming for the day.
Van Rules and Expectations:
Backpacks should be taken off before sitting in a seat. Students must walk to and from the PROPEL van. Students must keep all hands and legs to themselves. Remain seated at all times. Students must use quiet voices when in the van: foul language will not be tolerated. Eating and drinking inside the van is NOT permitted. Parents/guardians will be responsible for the cost of repairs and damages caused by your child. Students must be on time for van pick up. The van will not wait.
Automatic Suspension from Van Privileges:
Physical threat or harm to other students and/or the driver.
Fighting, smoking, drugs, or inappropriate touching while in the van.
Damage to property.
Bullying.
Belligerent behavior.
Consequences for NOT Following the Rules:
1st offense: Staff will speak with the student.
2nd offense: Driver/Propel staff will issue an incident report; parents will be notified. The student may be suspended from riding in a van for a defined period.
3rd offense: Student will have van privileges permanently removed
Student Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Waiver and Release
The parent or legal guardian is hereon referred to as Releasor.
Photo/ Social Media/ Marketing Release:
I/we understand that my child may be photographed or videoed for program documentation and marketing purposes. I/we allow the above-named minor to participate in PROPEL activities and allow PROPEL and its partners to use photographs of my child for publicity purposes, including the PROPEL website, social media, newsletters, and marketing releases.
Medical Release:
I/we authorize PROPEL to obtain and give consent to emergency medical treatment. In the event that I/we cannot be reached in an emergency, I give permission to emergency medical personnel to treat and transport my child as necessary for medical care, the emergency physician to hospitalize, secure treatment for, and order injections, and/or anesthesia, and/or surgery for my child.
In consideration for my child being permitted to participate in any PROPEL activities, I/we hereby release from liability and hold PROPEL harmless from any and all claims and causes of actions which might arise out of any activity conducted by or under the control of PROPEL, its employees, administrator, agents, volunteers, Board of Directors or trustees, sponsors, and assigns (hereon referred to as Releases). Releasor(s)-(parent or legal guardian) agree to release, hold harmless and forever discharge Releases of and from any and every claim, demand, action or right of action, of whatsoever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident which may occur as a result of participation in PROPEL or any activities in connection with PROPEL, whether by negligence or not.
Releasor(s) (parent or legal guardian) hereby assumes full responsibility for the risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while in or upon PROPEL property, vehicles, or otherwise while involved in any PROPEL activity whatsoever and wherever.
Releasor(s) hereby agrees to indemnify the Releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of Releasor(s) in any PROPEL activity, upon any property occupied or used by PROPEL for its activities, any vehicles used in the course of and/or scope of PROPEL activities, whether caused by the negligence of Releasees or otherwise.
Releasor expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Parent/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PRINT NAME:
*
Preview PDF
Submit
Should be Empty: