Detroit After School Fun Centers Program Application

A partnership of the Detroit Parks and Recreation Department & Detroit Public Schools Community District

Location*

Participant Information

First Name

Last Name

Birthdate

Gender

Male Female

Medical Problems or Restrictions:

Allergies:

Family Information - To be completed by parent/guardian

Parent/Guardian Name

Address

City

Zip Code

Phone Number

Current School

Emergency Contact Information

First Name

Last Name

Relationship

Address

City

Zip Code

Phone Number

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)

1. Name

Relationship

Contact Number

2. Name

Relationship

Contact Number

3. Name

Relationship

Contact Number

4. Name

Relationship

Contact Number

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:

Preferred Hospital:

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.

Agree*

Please check the box below to receive a confirmation

Send me a copy of my responses

Email address