REGISTRATION FORM

Please complete the form below and a Reach Out Community Center staff member will contact you. The program is offered for a suggested $25 donation per youth - no additional costs, which includes healthy snacks, activities and admission tickets for field trips. For further information about ROCC Youth Programs, contact programs@reachoutcc.org

Local youth ages 6-17 will have the opportunity to experience and learn a variety of educational and unique adventures. In coordination with The Chicago Police District 10th community room, Reach Out Community Center will be able to offer a taste of programs to come in the future once the rehab is complete. During the Fall Session kids will discover activities such as recycling, horticulture, martial arts, health and nutrition, tennis, creative writing, soccer, yoga, math, science, arts and crafts and more! There will be several field trips throughout the city of Chicago!  Reach Out Community Center is thrilled about the opportunity to start working with the local youth!   

 

Child's Name *
Child's Name
Birthday *
Birthday
Parent/Guardian's Name *
Parent/Guardian's Name
Address *
Address
Phone *
Phone
Emergency Contact *
Emergency Contact
Emergency Phone *
Emergency Phone
Permission to use Child's photo on webpage/brochures/social media/etc: *
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.

A $25 Suggested Donation is recommended to reserve your spot for the Summer Enrichment Program. This amount goes towards supplies, transportation, etc. You can donate here on our website, or in person on the first day of the program. 

$25 Suggested Donation