Student Governing Board (SGB) 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

There is a $50 Depot program registration fee to join SGB. Once your application has been accepted, you will receive a link to accept the position and pay the fee. Scholarship assistance is available. NO REFUNDS once committed to a Depot Program.

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 Program-SGB *

SGB (9th-12th grade, Tuesdays, 7:30pm)

SGB Required Essays

What personal qualities can you contribute to the Student Governing Board at The Depot? *

Please list your other activities (sports teams, clubs, Theater 308, etc.) for 2019-2020. Please keep in mind SGB meets every Tuesday at 7:30pm *

As a member of the SGB, I commit to running at least one event, and joining at least 3 committees. *

As a member of SGB, I will be expected to attend Tuesday night meetings, Depot events and volunteer at the Depot’s community service outreach projects. Community outreach is a big part of this Board’s commitment and that these projects/events are usually on the weekends. *

As a member of the Student Governing Board, it is understood I will complete 10 hours of community Service before January 2021 and 10 hours of Community Service before May 30, 2021 *

Please check here if we have your permission to re-print your answer in Depot marketing publications.

Yes, I give my permission to have The Depot reprint my response

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
Safety Fair
Other

The Depot’s mission is to build confident youth in our community! The Depot offers a connected and inclusive environment while providing essential programming and leadership development.