Summer Program Roster

Student's Full Name *

First Name

Last Name

Student's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Full Name *

First Name

Last Name

Parent/Guardian Phone Number *

(###)

###

####

Emergency Contact Full Name *

(Other than parent/guardian)

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Does your child have any allergies or dietary restrictions? *

Yes

No

Does your child have any medical conditions or take regular medications? *

Yes

No

Does your child have any physical limitations that may impact participation in activities or field trips? *

Yes

No

Can your child attend all 8 Saturdays from June 28–August 16, 2025? *

(Check all dates they WILL be attending)

June 28th

July 5th

July 12th

July 19th

July 26th

August 2nd

August 9th

August 16th

Are you committed to ensuring your child arrives by 9:00 AM and is picked up by 1:00 PM each Saturday? *

Yes

No

Will your child be attending the Golf Outing on Saturday, July 26, 2025? *

(This activity is free for students in our program. Parents get $50 off all tickets or towards $65 breakfast and lunch meals)

Yes

No

Unsure

I give permission for my child to participate in all RAWS program activities, including off-site field trips. *

Yes

No

I give permission for RAWS to transport my child for official program field trips. *

(If transportation is provided)

Yes

No

I give permission for RAWS to use photos and/or videos of my child for marketing, social media, and promotional purposes. *

Yes

No

I understand that RAWS is not responsible for lost or damaged personal belongings. *

I understand

I understand this is a free program, and attendance and engagement are expected each week. If my child misses more than two sessions without notice, their spot may be given to someone on the waitlist. *

I understand

Date

MM

DD

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