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2. Legal First Name*
3. Legal Last Name*
5. Chosen Name
6. Pronouns
8. Parent/Guardian Name(s)*
10. Parent/Guardian Email Address
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Home Phone*
21. Cell Phone
23. Work Phone
27. In Case of Emergency Contact*
29. Home Phone*
30. Cell Phone
32. Work Phone
36. Permission for participants to check themselves in and out of After School program and all B.L.O.C.K. functions:*

    My child has my permission to sign him/herself in and out at the beginning, and at the end of the After School program and all other B.L.O.C.K. functions. I understand that Leisure Services staff will not be responsible for my child and any other children I have taken responsibility for once they sign out and separate themselves from Leisure Services staff.

    1. Yes, I give my permission.
    2. No, someone will come in the building & sign my child out daily.
37. Permission to Record and Photograph Child Participating in Activities:*

    I hereby release to Canton Township rights to my child’s image, likeness, and the sound of his/her voice as recorded or photographed. I understand this recording or photograph may be edited and placed in publications, and thereafter the recording or photograph may be otherwise available. I agree to release, discharge, and save harmless Canton Township, including its representatives or designees, from any legal proceedings which may arise in relation to the conditions of the above paragraph.

    1. Yes, I give my permission.
    2. No, do not record or photograph my child.
39. Parent/Guardian Signature*
    (Type Name)
40. Date*
    Date
41. Parent/Guardian Signature*
    (Type Name)
42. Date*
    Date
44. Permission to Administer Questionnaires to Participants*

    I hereby give Canton Township my permission to administer questionnaires to my child for the purposes of improving future programs. I understand that the information collected from my child will remain anonymous and that my child’s identity will not be revealed in relationship to the survey.

    1. Yes, I give my permission.
    2. No, do not administer questionnaires to my child.
45. Waiver of Liability & Permission for Medical Consent:*

    In consideration of Canton Township permitting my child to participate in B.L.O.C.K. events off-site and providing transportation to and from said events, I, on behalf of myself, my child, my heirs, successors and assigns, hereby release Canton Township, its elected and appointed and officials, and its employees, volunteers, and agents, as well as the representatives of any other organization connected with this event, from any and all claims for liabilities or damages for any and all property damage or injuries which my child may suffer while taking part in any activities connected with this event. In case of injury, and I am unable to be contacted by your staff, I give my consent to have medical treatment administered to my child if deemed necessary by a physician and understand I shall be liable for any costs associated therewith.

49. Please add any information regarding health conditions, allergies, or anything staff should be aware of. The more information we have, the better we can help your child.
51. Additional Emergency Contacts (List Name, Phone Number, Relation to the Participant)
55. For grant funding purposes:

    What is the total household income?

    1. $0-$10,000

    1. $10,000-$25,000

    1. $25,000-$50,000

    1. More than $50,000
59. Required:*

    By checking "yes", I certify that the information contained in this application is accurate. I Agree:

    1. Yes
    2. No
61. Required:*

    I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the signer, and further that I agree to the above Terms of Acceptance.

    1. Yes
    2. No
63. Parent/Guardian Signature*
    (Type Name)
64. Date*
    Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field