REGISTRATION FORM

If you are interested in participating in any of the programs at the Southside Community Center, please fill out and print the registration form below and bring it in anytime to the Center.  Registration is free and is a requirement for participation in any of the Southside Community Centers programs. (Special activities & Events do not require registration to participate.)

The ability for the Southside Community Center to continue to provide afterschool programming and activities relies heavily on our ability to obtain demographic information of the population we serve.  Please fill in the following information.

Today’s Date:___________________________  Gender:  Male_____  Female_____

Name:______________________________  Age:__________  D.O.B.________Grade:________

Current School: ____________________________________________________________

Home Street Address: _________________________  Apt: _____  City: ____________________

Racial Group

_____African American                                  _____Caucasian

_____Hispanic/Latino                                     _____Asian

Multi-racial (specify): ____________________________________________________________

NAME OF PROGRAM REGISTERED FOR:______________________________________________

EMERGENCY CONTACT INFORMATION

Name: _______________ Phone:_______________  Relation:_______________

Name: _______________ Phone:_______________  Relation:_______________

I, ______________________________, give permission for my child to participate in the Southside Community Center.

□  My child will be picked up by____________________________________

 

□  My child can walk home from the Southside Community Center

______________________________                                                                        __________________

Parent/Guardian signature                                                                                                 Date