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Summer Camp Enrollment Form

Child receives special services at school?
Child has medical concerns or allergies?

EMERGENCY CONTACT - Must be at least 18 and not listed above.

Household Information:
Information is collected for grant writing purposes ONLY

Child receives free or reduced meals at school
Policies and Procedures
Please initial below each statement

#1 Club Rule is simple RESPECT.
Club members are expected to respect the club, respect others, and respect themselves. The Club practices a progress discipline plan that begins with a warning, followed by loss of privileges and possible temporary suspension from the Club. If the behavior continues the child will be dismissed from the Club. Club staff will work with parents/guardians and the Club member in order to best benefit the child and the Club.

#2 The Club is not a licensed child care provider and operates under an open door policy. Therefore, the Club asks for your help as parents in communicating to your child that they are to remain under our care and within Club boundaries.
#3 The Club closes at 5:00 pm. Club members must check out with an adult teacher at the Club. Club members are not permitted to leave the Club and return at a later time on that same day, unless an arrangement is made with the Club staff and parents/guardians.
#4 The Club is not responsible for any personal belongings that a member brings to the Club. Staff members will not hold any member’s belongings. If a Club member brings their cell phone and it is used inappropriately it will be confiscated and only returned to a parent/guardian.
#5 I give my consent for my child to appear in photographs, newspaper articles, brochures, public-related materials, social media, and our website related to their participation in the Evanston Youth Club.
#6 The Club has my permission to use my child’s picture and first name in public relations materials. (If you do not want your child’s first name used please do not initial).
#7 The Club uses place-based education and works hard to teach members about their community. As such, we will take local field trips often. The Club occasionally offers out-of-town field trips for learning and incentives. Please initial if you allow your child to participate in these activities with the Club.
#8 The Club has my permission for my child (7th grade and up) to participate in lifestyle programs like Keepin It Real & Not a Number. Interactive curriculum designed to teach youth how to protect themselves from human trafficking, peer pressure, and substance abuse. PREP is an abstinence based course that teaches about pregnancy and STD prevention.
#9 I understand that if my child is ill or does not attend school, he/she is not able to attend the Club that day.
#10 I understand that in case of an emergency, a reasonable effort will be made to contact me and/or the listed emergency contact. In the event that we cannot be reached, I hereby give permission to the Evanston Youth Club to secure proper treatment for my child.
#11 I understand as a participant in the Club my child may be asked to help with the evaluation of the program. At the end of each program period, we conduct an evaluation to tell us how well the program is working. Your child’s school teachers may also be asked to help evaluate our programs by completing a survey. Your child may be asked to complete a short survey on their attitudes and beliefs about the program and their experiences. If you do not want your child to participate please contact Holly Slade-West at the Club, at 444-2582.
#12 I understand that the Club and its personnel are not responsible for personal loss or injury. The Evanston Youth Club would like every member to have a safe, positive experience every time they are at the Club. Please contact us at any time with any questions, concerns, or comments.
#13 I give the Club my permission to check my child’s PowerSchool in order to help my child be successful in school.
Add Another Child (if finished scroll to the bottom and hit submit)
Child #2 receives special services at school?
Child #2 has medical concerns or allergies?

Thanks for enrolling!

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