Youth Programs Registration form
SPRING 2024
Student's Name
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First Name
Last Name
Age
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Please Select
14
15
16
17
18
19
20
21
22
23
24
E-mail
*
example@example.com
Zip code
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What pronouns do you use?
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She/her/her
He/him/his
They/them/their
Ze/hir/hir
Are you currently in School?
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Please Select
Yes, I'm currently a High School Student
No, I am not currently in School
If you are currently attending school, please tell us where
Which of our programs are you interested in attending? (please pick just one)
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Urban Gardening - designed to empower and educate youth ages 15 to 24 about the benefits of sustainable food production, environmental conservation, and healthy lifestyles.
Media Arts - Offers high-quality, student-centered, production and theory course aimed at developing young creators to thoughtfully adapt and thrive in a variety of creative environments.
Bomba (Afro-Puerto Rican Music & Dance) - This program is perfect for anyone who is interested in learning more about bomba or who wants to deepen their understanding of this rich and important tradition. Apprentices will have the opportunity to learn from the best in the business and to become part of a vibrant and welcoming community.
Afro Caribbean Jazz - Students will learn the fundamentals of the jazz and Afro-Latin traditions of the Caribbean, as well as the next level of concepts that are essential for world music performance.
In case your first choice is not available, which of our programs would be your second choice? (please pick just one)
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Urban Gardening
Media Arts
Bomba (Afrocaribbean Percussion)
Afro Caribbean Jazz
Tell us a little more about you: Why are you interested in this/these program(s)? :
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0/400
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Parents Contact Information
This section is MANDATORY for all applicants under 18 years old
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact Person #1
First Name
Last Name
Emergency Contact Person #1 Phone Number
Please enter a valid phone number.
Emergency Contact Person #2
First Name
Last Name
Emergency Contact Person #2 Phone Number
Please enter a valid phone number.
Authorizations, Releases & Signatures
1. Do you accept / give permission for your child to participate in all activities at Segundo Ruiz Belvis and to receive basic first aid and/or any medical treatment, if necessary?
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Yes
No
2. Do you / Does your child have any allergies? If no, skip to Question #3. If Yes, please explain below:
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Yes
No
(OPTIONAL) Do you / Does your child need an Epi-Pen for allergic reactions? If Yes, please provide written instructions with the medication that is to be carried with the student at all times during class in a labeled bag.
Yes
No
(OPTIONAL) Do you authorize SRBCC and/or its representatives to administer an Epi-Pen according to the written directions that you have provided?
Yes
No
3. Do you / Does your child have any medical conditions? If Yes, please explain in space below:
*
Yes
No
If answered yes to previous question, please explain:
Please note: SRBCC staff will not administer any medications to students, but will monitor while the student self-medicates.
4. I authorize / I give permission for my student to be photographed during activities and for SRBCC and its partners to use my student’s photographic image in commercial or non-commercial publicity for their organizations and the partnership.
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Yes
No
Parent Signature
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