Fall 2020 Registration

Parent/Guardian Name

First Last

Parent Email

Cell Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Languages Spoken in the home

Other Parents/Adults With Pick-Up permission

Number of Students to Register

Student Name #1*

First Last

Birthday

Student's School Name

Grade*

Program Student is Enrolling In:*

Level 1 Life Enrichment ( preK- 2nd grade)
Elementary Life Enrichment (3rd grade - 5th grade
Middle School Life Enrichment (6th grade - 8th grade)
High School Life Enrichment (9th grade - 12th grade)
Virtual Only Programming (drop off & after school programming)

Student Name #2

First Last

Birthday

Student's School Name

Grade

Program Student is Enrolling In:*

Level 1 Life Enrichment ( preK- 2nd grade)
Elementary Life Enrichment (3rd grade - 5th grade
Middle School Life Enrichment (6th grade - 8th grade)
High School Life Enrichment (9th grade - 12th grade)
Virtual Only Programming (drop off & after school programming)

Student Name #3

First Last

Birthday

Student's School Name

Grade

Program Student is Enrolling In:*

Level 1 Life Enrichment ( preK- 2nd grade)
Elementary Life Enrichment (3rd grade - 5th grade
Middle School Life Enrichment (6th grade - 8th grade)
High School Life Enrichment (9th grade - 12th grade)
Virtual Only Programming (drop off & after school programming)

Student Name #4

First Last

Birthday

Student's School Name

Grade

Program Student is Enrolling In:*

Level 1 Life Enrichment ( preK- 2nd grade)
Elementary Life Enrichment (3rd grade - 5th grade
Middle School Life Enrichment (6th grade - 8th grade)
High School Life Enrichment (9th grade - 12th grade)
Virtual Only Programming (drop off & after school programming)

Are Students on Free or Reduced Lunch?

Yes
No

Other Siblings in the Home/Ages

Household Religion

Do students have a church home/place of worship they attend regularly (2 times a month)?

Yes
No

Parent/Guardian Authorization*

I give permission for The USC to use my child's picture and/or voice in promotional materials
I give permission for my child to ride with an adult representative of The USC, if needed (All USC volunteers complete an extensive application and undergo a background check each year)
I understand that if my child will be walking home they will only be allowed to do so if The USC has my written authorization on file (see USC representative to obtain this form).
I give permission for the USC to access my student(s) academic records from their school.

All boxes must be checked. Without authorization, your student's application will be denied.

School Academic Records Access (Canvas) information

Username Passwod

Electronic Signature

By typing my name here I understand that this constitutes a signature confirming that I acknowledge and agree to the above terms of the USC program

Upon submission, you will be directed to the Medical Form which must be completed as part of enrollment

Enrollment Form- 2020-2021