After-School Program Registration Winter-Spring 2024
Program Timing: The after-school program meets every Tuesday from 3:30PM - 5:00PM. Starting January 9, 2024.
Program Details: Homework Assistance, Snack, Skill-Based Learning
Event Address: 1000 Broadway Ave. East Mckeesport, PA 15035
Contact: Wes Sherry at (724)504-2537 [wesley.sherry@greenhouselab.org] 
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Student First Name: *
Student Last Name: *
Age of Student: *
Grade the Student is in: *
Student Address: *
Parent/Guardian "1" First Name: *
Parent/Guardian "1" Last Name: *
Parent/Guardian "1" Relationship to Student: *
Parent/Guardian "1" Cell Number: *
Parent/Guardian "2" First Name: *
Parent/Guardian "2" Last Name: *
Parent/Guardian "2" Relationship to Student: *
Parent/Guardian "2" Cell Number: *
Medical Insurance Company: *
Policy Number: *
Does Your Student Have Any Allergies? *
If yes, please explain. Life Threatening? *
Any physical, emotional, mental, or behavioral concerns or limitations the camp should be aware of? *
Has your child ever experienced: Seizures, Asthma, Diabetes, Heart Disease, Home Sickness, or other. *
Do you want your child to be dismissed to walk home? *
Please list the names and numbers of the people who have permission to take your child home. Your child will ONLY be released to these people. *
By checking below you agree that typing your name below is equivalent to an electronic signature *
I hereby consent to let my child participate in the Community Collective After School Program. It is understood that every precaution will be taken for the safety and well-being of my child, but in the case of accident or sickness, Community Collective, Inc. and Community Collective’s staff, volunteers, and board of directors are hereby released from any liability. In the case of medical emergency, I understand that hospital policy requires parental permission before treatment. However, parents/ guardians will be notified immediately of any medical emergency. *
I hereby authorize and give full consent to Community Collective, Inc. to use all photographs and video in which my child appears for their website, social networking platforms, publication materials, and/or promotional posts. I hereby approve the foregoing and consent to the use of photographs and video material subject to the terms mentioned above. I affirm that I have legal right to issue such consent.
I understand that safety precautions are being put in place due to COVID-19. Therefore, if my child shows any symptoms of illness, I am responsible for picking them up as soon as possible once notified. *
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