DEPOT MIDDLE SCHOOL PROGRAM APPLICATION, PERMISSION AND EMERGENCY FORM

Contact Information

Student First Name *

Student Last Name *

Parent Email *

School

Birth Date *

// (mm/dd/yyyy)

Gender

Grade in 20-21 school year

PARENT/GUARDIAN *

Parent/Guardian Cell Phone *

Address 1

State/Province

City

Zip

Emergency Contact *

Emergency Contact Phone *

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

All Depot middle school programs run from September-May and are free of charge.

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.

Student Signature *

2020-2021 Middle School Depot Youth Center Programs *

Middle School Girls After School Gamerz Club
6th Grade Garden Club (Fridays 3-4:30pm ) Session 1-March 26th-April 30th
6th Grade Garden Club (Fridays 3-4:30pm ) Session 2-May 7th-May 28th
Garden Club (7th & 8th grade girls, Wed, 3pm-Feb 24-March 31)
Garden Club (7th & 8th grade girls, Wed, 3pm-April7-May 19)
SADD-8th Grade (Oct-May-Bi-monthly, Thursdays, 3pm)
Friday/Saturday Night Depot (7th & 8th Grade)
Cops & Kids (Middle School, Monthly, Saturdays, times vary)

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
Other
Graphic Design/Communications
Safety Fair