Summer Breakout Registration

Student Name *

Date Of Birth *

Gender MaleFemale

School *

Current Grade * 1st2nd3rd4th5th6th7th8th

Parent/Guardian Name *

Parent/Guardian Email *

Cell Phone *

Work Phone

Address *

City *

State *

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:

My child must attend 80% of the program to remain enrolled. *
I agree

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.