2024 Summer Registration

Child's Name *

First Name

Last Name

Gender *

Male

Female

Child's Birthday *

MM

DD

YYYY

Phone *

(###)

###

####

Does your child have allergies?

Yes

No

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact *

(###)

###

####

Permission to use Child's photo on webpage/brochures/social media/etc: *

Yes

No

Release Agreement *

I, the parent/legal guardian of the above mentioned youth herein after referred to as the participant; request that the City of Chicago and Reach Out Community Center (ROCC) allow my child to participate as a Enrichment Program participant provided by ROCC. The participant's parent/legal guardian agrees to release indemnify, hold harmless, and defend the City of Chicago and ROCC and their officers, agents, and employees, from and against liability for any and all claims, liens, suits, demands, and/or action for damages, injuries to persons, including death, property damage (including loss of use), and expenses (including court costs and attorney's fees), and other reasonable costs arising out of or resulting from the participant's participation in, connection with, constitutional or statutory law, or based in while or in part upon the neglect of intentional acts or omissions of the City of Chicago, ROCC, or the participant, including but not limited to his/her/its heirs, executors or assigns. By electronically signing this release/agreement, the participant's parent/legal guardian hereby warrants that he/she has read and understands the release/agreement. The participant's parent/legal guardian's electronic signatures are affixed hereto of his/her own free will without any inducement or reliance on any person or promise. The participant's parent/legal guardian further warrants that he/she is of legal age and legally competent to execute this release/agreement.

Yes

No

Select Program *

2022 Summer Program

$75 Payment

Will you provide $75 per child on the first day or online?

Online

First day