Family Information

I would like to register children for:

Contact Details

Parent/Guardian Information

First Name

Last Name

Address Line 1

Apt. Number:

City

State

Zip Code

Phone

Email

Used for program updates only.

Parent/Guardian Birth Date

For age verification of the respondent.

Would you like to add a second parent/guardian OR an additional emergency contact?

Yes

No

Their first and last name:

Their Phone number:

Household Information: Does anyone in your household qualify for any of the following benefits: Free/Reduced School Meals, SNAP Benefits, Medicaid, Section 8/ CHA Resident?

Yes

No

This information is used when R CITY applied for grant funding to support our programs. This question is optional, but helpful for R CITY.

Have you, a family member or a close friend ever experienced any form of violence in our community?

Yes

No

Not sure, or prefer not to answer.

*Violence: ANY action that results in injury, death, or harm. This question is related to funding we receive specifically to care for people who have experienced violence or been in close proximity to someone who has.

Would you be interested in victims services provided by R CITY or one of our partners?

Yes

No

Maybe

Anything else you would like us to know about your children or your family?

Student Information Page

Fill this out for each child in your family.

Child's First Name

Child's Last Name

Child's Birthdate

Current Grade:

Current School

Optional: Student phone number?

Gender Identification:

Child's Race/Ethnicity: Check any that apply.

This information is used when R CITY applied for grant funding to support our programs. This question is optional, but helpful for R CITY.

Other

This child may walk home alone:

YesNo

If no, this child will be released to:

List any family members who are allowed to sign out your child at the end of programs.

Allergies or special needs?

If you have more than one child to register- don't forget to click the link "Add another child"

Waiver of Liability & Release of Information

1. As the parent/guardian, it is my responsibility to instruct minor participants if he/she believes anything is unsafe, the participant should immediately advise R CITY staff of such condition and refuse to participate.

2. The previously named minor(s) (“my child(ren)”) may, during the course of the program, participate in active play within and outside the River City facility at 3709 W. Grand Avenue. Locations for active play within close distance of 3709 W. Grand Ave. include but are not limited to Grand Playlot Park, Cameron Elementary School, Children's Garden of Hope, Kedvale Park, and Humboldt Park. I give permission for my child(ren) to travel with R CITY to these locations, either by walking as a group or by R CITY van transport.

3. I grant permission for my child(ren) to receive medical treatment for any and all injuries and illnesses sustained or experienced during his/her participation in R CITY summer activities, included but not limited to emergency first aid, emergency transport to a medical facility, and emergency treatment by medical personnel onsite or at a medical facility.

4. In consideration for my child(ren) indicated above enrolled to participate in R CITY programs, on behalf of myself, my family, my heirs, and my assigns, I hereby release River City Community Development Center and River City Community Church, their volunteers, and their employees from liability for injury, loss, or death to the above mentioned participant while using any facility or equipment or in any way associated with participating in the activity of being a participant in R CITY after school program.

5. I further understand that in the event that my child(ren) is/are an immediate danger to themselves or others, my child(ren) may be sent home immediately from the program at the time of the event. I understand that the staff will attempt to contact me immediately by phone and text if this happens.

6. This program takes place in the time of the COVID-19 pandemic. I understand that participation in any youth program creates an increased risk for my household to come in contact with the COVID-19 virus. Understanding that R CITY has put safety measures into place, I accept all liability for my child(ren) and household associated with COVID-19 through participation in this program.

7. I further consent River City Community Development Center the right to use, publish, or electronically transmit written stories about the minor participant, as well as his or her artistic product, photographic image, video, or audio recording for organizational or publicity purposes without compensation to myself or the minor. Your child will not be identified by name.

Image Release

I consent. DO NOT release stories/photos/video/art/audio of my children.

I have read the permission statements, and understand that by clicking the box below, I give my permission for the children registered on this form to participate.

Yes, I consent.

Black/African American	Hispanic/Latino	Native American
Asian/Pacific Islander	White/Caucasian	Other

Program Registration

Please complete the form below