SUMMER BREAKOUT REGISTRATION

*Required Information

Student Name *

Date Of Birth *

Gender MaleFemale

Please leave this field empty.

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:

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.

• Students must attend 80% of the program to remain enrolled.
  If someone not listed on the registration form will pick up students, a parent must inform VOICE staff in person or by phone (VOICE offices - Corsicana 903.872.0180 or Waco 254.741.9222).
• Students cannot arrive before 7:30 am and must be picked up promptly.
• Students can only walk home if permission is given on the registration form.
• VOICE is not responsible for lost or stolen personal items.