Connect Center Youth Permission Form

Please complete this form to finalize your child’s registration for Summer of S.T.E.A.M. This form is required for participation.

Student Information

Student First name

Student Last name

Address

Date of Birth

Month

Day

Year

Student Age

Current Grade

Preferred Pronouns

Parent / Guardian Information

Parent/Guardian Full Name

Phone

Emergency Contact

Emergency Contact Full Name

Phone

Relationship to Student

Medical Information

Does your child have any allergies or medical conditions?

Is your child currently taking any medications?

No known allergies or medical conditions

Program Enrollment

Please confirm your child’s enrollment for Summer of S.T.E.A.M.

Select your registration type

Dismissal / Pick-Up Plan

How will your child be dismissed?

Walking home

Picked up by parent/guardian

Picked up by someone else

Name of authorized person

Permissions & Consent

I give permission for my child to participate in Connect Center programs

I give permission for my child to be photographed or recorded for program use

I authorize the Connect Center to seek emergency medical treatment if needed

Code of Conduct

Please review the expectations below. All students are required to follow these guidelines while participating in Connect Center programs.

I will listen to and follow instructions given by the Connect Center team.
I will not engage in disruptive activities, such as running, being on the phone, or excessive screaming.
I will keep my hands to myself.
I will use kind and appropriate language when speaking with peers, volunteers, and staff.
I will not touch or take other people’s belongings without permission.
I will clean up after myself to help keep the Connect Center clean and organized.
I will respect the Connect Center and everyone in it.
I understand that if I am spoken to multiple times for behavior, I may be asked to leave.
I will not bring weapons or harmful items to the Connect Center.
I will not enter restricted areas without supervision.

I have read and agree to the Connect Center Code of Conduct. I understand that failure to follow these expectations may result in removal from the program.

Parent / Guardian Confirmation

Parent / Guardian Confirmation/ Signature

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Today's Date

I certify that the information provided is accurate and I agree to the Connect Center policies and permissions outlined above.