Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Child's Name *

First Name

Last Name

Grade your child will be in Fall 2024 *

1st

2nd

3rd

4th

Date of Birth *

MM

DD

YYYY

In the event of an injury requiring medical attention, I grant permission to the supervising Director(s) or staff (including volunteers) to attend to my child. If the injury warrants further medical attention, every effort will be made to contact me to receive my specific authorization before action is taken. If efforts to contact me are unsuccessful, I grant permission for necessary medical treatment to be given. I agree to accept full responsibility for costs of medical care and transportation incurred in such an event. *

By typing your name here, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

First Name

Last Name

While your child is attending STEP’s Summer Enrichment it is expected that every child display obedient and positive behavior. Respect and responsibility are expected. Any displays of the following behavior, or other behavior deemed inappropriate, will not be tolerated and may result in early dismissal: 1) Any negative speech to leaders or other participants. 2) Offensive comments, lying, explicit language, etc. 3) Aggressive behavior, either verbally or physically. 4) Damaging private property. 5) Harming another person. *

By typing your name here, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

First Name

Last Name

By enrolling my child in Summer Enrichment, I acknowledge that STEP may use my child’s photo or other digital images to promote the Summer Enrichment Program, the Victory Reading Program and the STEP ministries. *

By typing your name here, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

First Name

Last Name

I understand that all activities entail potential risk of harm, bodily injury, or illness. I voluntarily agree to accept any risk of harm, injury, or illness (including COVID-19) arising from my child’s (or the child whom I am registering for this program) participation in this program including those that may arise while transporting my child (or the child whom I am registering for this program) to and from any associated activities, and I hereby release STEP ministries from any and all liability for any injury, illness or other damage resulting from the program activities. *

By typing your name here, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

First Name

Last Name

Total household annual income, including wages/salaries, social security income, pensions, dividends/interest, SSI, etc.: (This information is kept confidential and used for funding purposes only.) *

$0-$15,060

$15,060-$20,440

$20,440-$25,820

$25,820-$31,200

$31,200-$36,580

$36,580-$41,960

$41,960-$47,340

$47,340-$52,720

$52,720+