Rise Up! After-school Program Registration
Please complete the following form to register your student for the Rise Up! after school enrichment program with Richmond Heights Local School District. The Rise Up! program provides students with academic tutoring and homework help, as well as student enrichment clubs through social-emotional learning, clubs, and mentoring. Rise Up meetings daily from 2:45 - 5:15 and 1:30 - 3:30 on Wednesdays. Transportation is provided and this is a FREE program!
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Student First and Last Name *
Student Date of Birth *
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Student Address *
Student Grade *
Parent/Guardian First and Last Name *
Parent/Guardian Phone *
Parent/Guardian Email *
What is your preferred form of communication? *
Does your child take any prescribed medications? *
If yes, please list the medications and doses below.
Does your child have a mental, emotional, health and/or behavioral diagnoses? (e.g. ADHD, diabetes, anxiety, asthma, etc.) *
if yes, please describe below.
Rise Up! provides students with transportation after school. However, parent/guardian pickup is also permitted. Please list any contacts who have permission to pick up your student from Rise Up! *
Emergency Contact Name *
Emergency Contact  Number *
Emergency Contact Name *
Emergency Contact Number *
Emergency Contact Name *
Emergency Contact Number *
By placing an electronic signature below, you agree to enroll your student in the Rise Up! after school program. Rise Up! is a voluntary program. Students are not required to attend unless advised by a parent or Richmond Heights Local School District faculty or administration. Please provide the first and last name of a parent/guardian below. *
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