Name
*
First Name
Last Name
DOB
*
MM
DD
YYYY
Gender
*
Female
Male
Prefer not to specify
Race
*
Black or African American
Hispanic or Latino
Native American or Alaska Native
Asian
Native Hawaiian or Pacific Islander
White/Caucasian
Prefer not to specify
Student's preferred name
*
Student's home address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
2024–2025 School name
*
2024–2025 School year grade
*
Kindergarten
1
2
3
4
5
6
7
8
Name
*
First Name
Last Name
Relationship to student
*
Cell phone number
*
(###)
###
####
Email
*
Home address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about Rise After School?
*
Please check at least two possible areas of interest for your participation.
*
How many children in your family currently participate in any of Rise’s programs? (This includes Rise After School, Rise Academy, and Rise Labs.)
*
Do you or your children currently receive government assistance? (This includes SNAP/TANF.)
*
Has your child/children ever qualified for free and reduced lunch?
*
Select the income range that best describes what your household earned last year. (This includes what you received in government assistance.)
*
Less than $10,000
$10,000–$20,000
$20,000–$30,000
$30,000–$40,000
$40,000–$50,000
$50,000–$60,000
$60,000–$70,000
$70,000–$80,000
$80,000–$90,000
$90,000–$100,000
$100,000+
If above $100,000, please estimate your annual income.
How many people are supported by this income? (This might be the number of people currently living in your home.)
*
Please indicate your student's transportation plan.
*
Adult 1
First Name
Last Name
Relationship to student
Cell phone number
(###)
###
####
Adult 2
First Name
Last Name
Relationship to student
Cell phone number
(###)
###
####
Please list any adults who DO NOT have permission to pick up or drop off your student.
Contact 1
*
First Name
Last Name
Relationship to student
*
Cell phone number
*
(###)
###
####
Contact 2
*
First Name
Last Name
Relationship to student
*
Cell phone number
*
(###)
###
####
Does your student have any allergies?
*
If yes, please list.
Does your child require an EpiPen for allergic reactions or an inhaler/nebulizer for asthma?
*
If you answered "Yes" to an EpiPen or inhaler, are you willing to provide one to Rise After School to have on-site if needed?
Does your child have any special physical, emotional, or medical needs?
*
If yes, please list.
Medical insurance company name
*
Policy holder's name
*
Policy number
*
Photo release
*
I give permission for photos of my student (taken while participating in Rise After School activities) to appear in Rise Richmond's digital and print publications, to include the website, social media, and promotional materials. I understand that photos may occasionally be shared with trusted partners for the purposes of grant reporting, etc.
Video release
*
I give permission for my student's image/likeness to be recorded on video in group settings. (Note: If Rise Richmond would like to individually feature your child/family, we will request specific consent from you in advance.)
GENERAL CONSENT
THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPANT CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN. By completing and signing this form, I, the undersigned parent/guardian of the above listed minor (if participant is under the age of 18), acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions, or negligence, but action, inaction, or negligence of others; the rules of play; or the condition of the premises or of any equipment used; and further, that there may be other unknown risks not reasonably foreseeable at this time; assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability, or death, hereby release, discharge, covenants to indemnify and not to sue Rise Richmond, its directors, officers, employees, managers, agents, sponsors, and associated personnel, including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as ‘releasees,’ from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the programs. I hereby give my consent to have a doctor of medicine or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim, or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above waiver/release and understand that I have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alteration without the express written consent from Rise Richmond will cause the participant to be removed from the program (revised 6/01/2017). By completing and signing this form, I do hereby authorize my child to participate in any and all activities held by Rise Richmond, Inc., a Virginia nonprofit organization. Such activities include but are not limited to the following: tutoring, mentoring, Bible studies, life skills training, arts and crafts, sports, music and dancing, community service activities, meals and snacks, and also a series of field trips that could include but are not limited to outdoor activities as well as Rise Richmond-provided transportation to attend these activities. Having authorized my child to participate in Rise Richmond programs, I further agree as follows: (1) I will not hold Rise Richmond liable for and hereby release any and all claims that I or my child may have as a result of my child’s participation in the above-stated activities. (2) I understand that Rise Richmond may at times need to send and reply to emails, texts, and other electronic messages from youth to communicate about programming; such contact will be limited to programmatic hours. (3) I understand that most of Rise Richmond’s activities will occur at one of the facilities in the East End of Richmond listed below). I hereby agree that my child has permission to attend Rise Richmond activities at the following locations and I further agree not to hold any property owner liable for and hereby release any and all claims that I or my child may have for any liability against the property owner that results as a part of my child’s involvement in Rise Richmond: CHAT Properties, LLC 3015 N St, Richmond, VA 23223 and Carlisle Ave Baptist Church 2010 Carlisle Ave, Richmond, VA 23231. (4) I fully understand that the program involves volunteer mentors, who shall be selected from the community and will be screened (including a criminal background check) and trained before beginning in the program. *In the event I wish to revoke any part of the permission granted hereunder or cancel any part of this agreement, I agree that I will provide a notice of such revocation in writing to Rise Richmond (3015 N St. Richmond, VA 23223) and that the provisions of this agreement shall remain in effect until the receipt of such written notification by Rise Richmond. *This agreement, and the interpretation hereof, shall be governed exclusively by its terms and by the law of the Commonwealth of Virginia, without reference to its choice of law provisions. This agreement sets forth all of the promises, agreements, conditions, and understandings between the parties respecting the subject matter hereof and supersedes all prior negotiations, conversations, discussions, correspondence, memoranda, and agreements between the parties concerning such subject matter.
By typing my name below, I indicate that I have read and understand the above application.
Name of parent/legal guardian
*
Today's date
*
MM
DD
YYYY
