DEPOT HIGH SCHOOL PROGRAMS APPLICATION, PERMISSION AND EMERGENCY FORM

2020-2021 Applications are due June 11, 2020. Questions please contact Janice@dariendepot.com

Contact Information

Student First Name *

Student Last Name *

Student Email *

Student Cell Phone *

School

Birth Date *

// (mm/dd/yyyy)

Gender

Grade in 20-21 school year

PARENT/GUARDIAN *

Parent/Guardian Cell Phone *

Parent/Guardian email *

Address 1

State/Province

City

Zip

Emergency Contact *

Emergency Contact Phone *

All programs this year will receive a Depot t-shirt, with the Depot logo on front and list of Depot programs on back.

T-Shirt Size *

DEMOGRAPHICS

We collect the following information to include in grants that go towards funding Depot programs. Your name will be kept confidential. Only your demographics will be provided. Thank you.

Free/Reduced Lunch *

Ethnicity *

Family *

Annual Household Income *

Members In Household

PERMISSION AND EMERGENCY/MEDICAL INFORMATION

Allergies/Medical Conditions

In case of emergency, if I cannot be reached, I give permission to the attending physician to hospitalize, secure necessary treatment, order injections, anesthesia, or surgery for my child named on this form. Additionally, I, the undersigned, do hereby waive and hold THE DEPOT YOUTH CENTER, its employees and agents, harmless from any personal or property damage I or my child may incur while participating in activities at THE DEPOT YOUTH CENTER. I also understand THE DEPOT YOUTH CENTER does not provide accident or health insurance. In addition, I give permission for my child to participate in all programs at THE DEPOT YOUTH CENTER.

Parent Signature *

PROGRAM REGISTRATION

Please check the box next to the program(s) you would like to participate in below. New this year, every program requires a $50 registration fee per student. Scholarship assistance is available please contact: Janice@dariendepot.com. NO REFUNDS

Please note the day/time programs are offered. Do not sign up for a club that conflicts with your schedule. Space is limited for most programs and are first come, first serve, unless noted otherwise.

Commitment Policy: By signing here, I understand I am only allowed 3 unexcused absences throughout the year. If I exceed this amount, I understand I will be dismissed from the program. All Depot programs run from September-May.

Student Signature *

2020-2021 High School Depot Programs

Girls Night Out (9th-12th grade girls, Mondays, 6pm)
SLOD (9th-12th grade boys, Mondays, 8:30pm)
Smiles for South Dakota
SADD-HS
Respect Works
Volunteer Club
Helping Hands

If you are signing up for SADD, please tell us why you are interested in joining SADD in 250 words or less.

Program Registration Fee *

Program Fee $50

THE DEPOT NEEDS YOUR HELP! PARENT INVOLVEMENT OPPORTUNITIES

The Depot Board of Directors strongly encourages that all Depot parents contribute to The Depot in some way. Our success, as in any organization, depends on the commitment of many. Please support The Depot in at least one of the following areas. We will contact you with further details:

Fundraiser Events
Graduation Balloons
Town Wide Mailing
4th-6th Grade Parties
Graphic Design/Communications
Publicity
Safety Fair