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Select one or more classes *

Child's Name *

First

Last

Birthdate *

Gender *

Male
Female

Grade *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Parent or Guardian *

First

Last

Phone Number of Parent or Guardian *

Email Address of Parent or Guardian *

Name of person picking up child after program *

Phone number of person picking up child after program *

Enter as 10 consecutive digits, no ( ) or - characters. Thank you!

Does your child have access to a computer? *

Does your child have access to the internet? *

On a scale of 1-5, how much does your child enjoy reading? (1-least, 5-most) *

What was your child's Reading/ELA MCAS score in 2022? *

Is your child enrolled into ELL (English Language Learners) or LEP (Limited English Proficiency) group at school?

On a scale of 1 to 5, how much does your child enjoy math? (1-least, 5-most) *

What was your child's Math MCAS score in 2022? *

Does your child have an IEP? If yes, we need a copy of the IEP.

Does your child have food allergies? Please list, if any.

Does your child have any medical concerns, allergies, or daily medications? Does your child have a 504 medical plan? If yes, please inform our Executive Director and bring in a copy of the 504.

We/I the parent(s) and/or legal guardian(s) of the above mentioned child, hereby give permission for said child to participate in the Summer STREAM Club program, sponsored by Children Across America. We/I acknowledge that our/my child's participation in this activity is voluntary and is within the discretion of the Children Across America and, in consideration thereof, we/I hereby release the Children Across America’s Directors and volunteers, and their employees from any and all claims which We/I or our/my child may have as a result of suffering personal injury, food allergy in any way arising from or related to participation in the above-described activity, resulting from any act or omission of Children Across America’s Directors and volunteers, and their employees. We/I, on behalf of ourselves/myself and our/my above-named child hereby expressly waive in advance any and all rights to sue which we/I and/or our/my child may have against Children Across America’s Directors and volunteers, and their employees to recover for any loss, damage or expense of any type in any way arising from or related to said child's participation in the above described activity. We/I expressly agree to indemnify and hold harmless Children Across America’s Directors and volunteers, and their employees from any and all loss, damage, or expenses, including court's costs and attorney's fees, which they or any of them suffer as the result of our/my above named child or anyone on the child's behalf filing a civil action against Children Across America’s Directors and volunteers, and their employees, in any way arising from or related to said child's participation in the above-described activity at any time either prior or subsequent to said child's eighteenth birthday. *

Date / Time *

I understand that my photograph(s) is (are) under consideration for publication on the Children Across America world wide web page, a part of the internet, brochures, or other print marketing documents. I grant permission for the publication of mine or my children’s photograph(s) for use by Children Across America on the wide world web page, social media or other print marketing documents.

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