ARM AFTER SCHOOL PROGRAM REGISTRATION
Program Hours: 3:30-5:30pm (Mon-Wed)
Address: 1002 Four Seasons Blvd. - Aurora, IL 60504
Contact us at (630) 476-0171 - DAVID SMITH
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PARTICIPANT INFORMATION:
Student Name *
Date of Birth *
MM
/
DD
/
YYYY
School Name *
Student Email
GPA
Age *
School District *
Does your child receive free/reduced lunch or TANF *
PARENT INFORMATION:
Parent Name(s) *
Home Address *
City *
State *
Zip *
Phone Number
Cell Number *
Parent Email *
EMERGENCY INFORMATION:
Name *
Relationship *
Address *
City
 *
State
 *
Zip
 *
Phone Number
Cell Number *
HEALTH HISTORY:
Doctor Name *
Phone Number *
Please check if student has any of the following and list details below: *
Required
Details of health condition(s) checked above
Does applicant take any medications? *
Will student be taking any medication while in this program? *
If Yes, please list with details:
Our after school program offers to help students by monitoring their Infinite Campus Student Portal for missing assignments and grades that need improving. If you would like the program to provide this service please submit their username and password.
Infinite Campus Student Portal Username *
Infinite Campus Student Portal Password *
TRANPORTATION TO ARM COMMUNITY CENTER
Check how your child will get to the ARM Community Center *
Required
The following individuals are authorized to drop off and pick up my student:
PARENT'S AUTHORIZATION
By submitting this registration form I hereby give consent for my child to participate in the At Risk Mentoring (ARM) after school program and all program related activities. I give permission for ARM to use any photos or videos of my child for promotional purposes. To the best of my knowledge, my child is in good health and I will notify ARM if he/she is exposed to any infectious diseases. I further release and agree to indemnify and hold harmless ARM and its staff, volunteers, community partners, school district and assigns from any liability concerning our child's involvement in the program and further agree that the use of all ARM facilities is made at the risk of the applicant. 
Parent/Guardian Consent (in lieu of signature) *
Required
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