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Name of Child *
Name of Child
Date of Birth *
Date of Birth
Address *
Address
Gender *
Examples: Black, White, Hispanic, Asian, Black & White, etc.
Name of Contact #1 *
Name of Contact #1
Contact #1 Phone Number *
Contact #1 Phone Number
Name of Contact #2 *
Name of Contact #2
Contact #2 Phone Number *
Contact #2 Phone Number
Name of Contact #3
Name of Contact #3
Contact #3 Phone Number
Contact #3 Phone Number
Disclosures and Agreements
The Southside Community Center
offers free year-round programs, activities, and homework help to all youth ages 5 to 18. We serve a free snack right after school and free dinner at 5:00pm. Program hours end at 6:00pm.
Medical Emergency
The Southside Community Center has permission to treat your child in case of an emergency, including calling an ambulance. It is your responsibility to inform and update the Southside Community Center of any allergies or medical concerns in writing.
Photo Permission *
The Southside Community Center, if responded with “YES” below, may use your child’s image in media in print (flyers, posters, etc.) and the internet (social media, website, etc.).
Drop-In
The Southside Community Center is a “drop-in” center, and we cannot force your child to stay on the property. You are responsible for discussing with your child where they can and cannot go, and whether or not they may leave without an adult. The Southside Community Center is not responsible for lost or stolen property.
Your Name *
Your Name
Today's Date *
Today's Date
I agree with the terms and disclosures above. *