Summer Breakout Registration

Students increase their love of education and learn healthy behaviors during the multi-week program.

    Student Name *

    Date Of Birth *

    Gender MaleFemaleUndisclosed

    School *

    Current Grade *

    Parent/Guardian Name *

    Parent/Guardian Email *

    Cell Phone *

    Work Phone

    Address *

    City *

    State *
    Texas

    Zip *

    Emergency Contact Name *

    Cell Phone *

    VOICE has permission to take and use photos/videos of my child. *
    YesNo

    VOICE has permission to seek emergency medical care for my child. *
    YesNo

    My child has special medical needs or food allergies. *
    YesNo

    If yes, please explain:

    My child has permission to walk home from the program site. *
    YesNo

    My child has permission to be picked up from the program site by:

    I understand my child must attend 80% of the program to remain enrolled. *
    Yes

    I give permission for my child to attend Summer Breakout. I agree to release and hold harmless VOICE and all VOICE representatives from any and all liability and claims as a result of my child’s participation in Summer Breakout activities. *
    YesNo

    A copy or picture of the student’s most recent report card must be attached.