Expeditions

Summer Digital Media Lab

Grades: 6^th – 8^th - Mondays

Grades: 9^th – 12^th - Wednesdays

Times: 5:00pm – 7:00pm

FREE / NO CHARGE!

During this summer's Digital Media Lab, students will learn photo, video and audio editing skills using Apple iPads. Summer projects will explore our Northeast community of friends, family members, neighbors and residents as we create media projects that reflect the youth and communities they are part of. This course is supported by a generous grant from GOOGLE. Program begins Monday, June 17th!

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Contact Information

Parent/Guardian First Name

Parent/Guardian Last Name

Address

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Child Information

Please register my child for the following program:

Child's First Name

Child's Last Name

Child's Birth Date

Gender

Race

Are you Latino/a or Hispanic?

If no, what is your ethnicity?

What is your country of origin?

Disability

If yes, what accomodations are needed?

Language Preferred

School

Grade

What other programs are you involved in at Mattie Rhodes Center?

Emergency Contact Info

Emergency Contact

Emergency Contact Relationship to Child

Authorized Pick Up Phone

Emergency Contact 2

Emergency Contact 2 Relationship to Child

Phone 2

Household Demographics

Relationship Status

Religion

Household Gross Income

Female Head of Household

Number in Household

Do your children qualify for?

How long has your family lived in Kansas City, MO?

How did you hear about this program?

If other, please explain

Are you in the Military?

Skills and Experience

CONSENT FORM By checking the boxes below, you acknowledge and consent to the following:

I release Mattie Rhodes Center (MRC) from liability for any injury that may occur on MRC premises, during transportation, or during program participation.

I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of myself or my child/dependent.

I give MRC and my permission to use photographs of my child/dependent or myself taken during programming for MRC marketing use.

I give my permission for my child to be escorted by MRC staff to the programming site (MRC-Northeast, James Elementary or the Jubilee Garden) Fieldtrips will require a separate form to be signed by the parent/guardian.

I give MRC my permission for staff to have access to my child’s attendance, grades and discipline records through their schools to track academic achievement for grant funding purposes.

Doctor to notify: Name

Phone

Allergy Info

After programming, my child/dependend will...

Participants of all ages are expected to exhibit appropriate behavior. A participant, who displays ongoing inappropriate or unmanageable behavior, including harassment, may be asked to leave the premises or be removed from the group. Police assistance will be requested when the participant is dangerous to self or others or has the potential to be dangerous to self or others.

Please list any behavior or safety issues we should be aware of:

SOCCER FOR SUCCESS ONLY! I give permission to Mattie Rhodes Center and the U.S. Soccer Foundation to collect and record data, including Body Mass Index (BMI) weight and height and waist/neck circumference, about my child with the understanding that all information obtained will remain private, and that any responses publicly reported will be grouped together with other participants of this program and that my child will not be individually linked to his/her response. Only the staff approved by the U.S. Soccer Foundation will be able to view his/her responses.

IMPORTANT! EXPEDITIONS ONLY! I understand that if my child is enrolled in the Expeditions program they will attend presentations, receive information on and participate in discussions on risky behaviors affecting teens today. These topics include, but are not limited to: drug/alcohol abuse, domestic violence/unhealthy relationships, bullying, teen pregnancy, gang activity, teen suicide, etc. IF YOU CHOOSE NOT TO INITIAL THIS REQUIREMENT, YOUR CHILD CANNOT PARTICIPATE IN THE EXPEDITIONS PROGRAM.

I confirm the truthfulness of the information provided in this form. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to MRC's Terms of Acceptance. I acknowledge my understanding and receipt of and/or directions how to access the following information on MRC Programming (www.mattierhodes.org), the Letter of Understanding (which includes Behavior Support and Interventions), the Grievance Procedure, the Parent Handbook (if applicable) and the Notice of Privacy Practices (if applicable.)

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