Detroit After School Fun Centers Program Application
A partnership of the Detroit Parks and Recreation Department & Detroit Public Schools Community District
Brenda Scott, 18440 Hoover - 4pm-6pm
Burton International, 2001 Martin Luther King Blvd. - 4pm-6pm
Charles Wright, 19299 Berg - 4pm-6pm
Earhart, 1000 Scotten - 4pm-6pm
Gardner, 6528 Mansfield - 4pm-6pm
Gomper, 14450 Burt Rd - 4pm-6pm
John R King, 15850 Strathmoor - 4pm-6pm
Mackenzie, 10147 W. Chicago - 4pm-6pm
Ronald Brown, 11530 E. Outer Dr - 4pm-6pm
Schulz, 10700 Santa Maria St - 4pm-6pm
Wayne, 10633 Courville St - 4pm-6pm
Medical Problems or Restrictions:
Family Information - To be completed by parent/guardian
Emergency Contact Information
1. Participation conveys the privilege of program involvement for scheduled activities.
2. Participation may be revoked due to any of the following: a) Criminal Activity; b) Refusing to comply with Program Rules; c) Continued disruptive behavior; d) providing false information on application.
Child will only be released to those names listed here
(proof of identification required)
Emergency Medical Authorization
Please Check One:
I GIVE permission to secure emergency medical and/or emergency surgical treatment for the above named child while in care.
I DO NOT GIVE permission to secure emergency medical and/or emergency surgical treatment for the above named child while in care.
Health Insurance Provider:
Policy or Group Number:
My child’s health appraisal and immunization records, or appropriate waiver are on file and current at:
(please provide school name). I acknowledge that my child is in good health and assume responsibility for his/her state of health.
By submitting this application, I hereby agree to abide by all rules and policies of the City of Detroit, the Detroit Parks and Recreation Department and Detroit Public Schools Community District.
Please check the box below to receive a confirmation
Send me a copy of my responses
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