One-Time Drop-In Registration

Student Name *
Student Name
she, he, they, etc.
Student Birthdate *
Student Birthdate
during summer, this refers to the grade student will be entering
Program Interest
Phone *
Address *
Student's primary residence
Parents/Guardians will always be our immediate contacts, please provide an additional contact in the event we are not able to reach parents/guardians
Emergency Contact Phone *
Emergency Contact Phone
Please also indicate if student is permitted to leave by themselves
Please inform us of any allergies or health concerns (including any and all medications) which may be pertinent to our time with your student. Please also include any special information you feel would help us create a safe and supportive environment for your student
Emergency Care Authorization *
In the event of serious accident or injury, every effort will be made to contact a parent or guardian. Because I understand that a situation could arise when first aid and/or emergency treatment may be necessary and I cannot be reached, I hereby authorize Read and Write Kalamazoo personnel to make provisions for treatment with the appropriate medical personnel or facility. I also understand that in the event my student (who is under the age of 18) needs to be taken to an emergency room, they will be taken to Bronson via ambulance (as Borgess does not provide pediatric emergency services).
Typing your name here is a digital signature confirming your response to the above Emergency Care Authorization
Photo Release *
I permit Read and Write Kalamazoo to take photographs of my student for the explicit purpose of chronicling and promoting the RAWK program. I understand that any photographs of my student taken during RAWK programming will not be used by anyone not affiliated with Read and Write Kalamazoo.
Demographic Information
Eligible for free or reduced lunch?