Workshop Registration

Student Information

Student's First Name *

Student's Last Name *

Student's Gender Pronouns *

she/her/hers

he/him/his

they/them/theirs

other

(check any that apply to your identity)

Student Birthdate *

00/00/0000

Grade Level (2020–2021 school year) *

During summer, this refers to the grade student will be entering.

Student School *

Languages Spoken at Home *

Camp Information

Select Camp *

Schedule Availability - Group Session *

10:00 AM (Monday–Friday)

12:00 PM (Monday–Friday)

2:00 PM (Monday–Friday)

We will try to accommodate individual schedules as much as possible, please indicate which daily sessions would work best for your Student.

Schedule Availability - Individual Sessions *

11:00 AM (Wednesday–Friday)

1:00 PM (Wednesday–Friday)

3:00 PM (Wednesday–Friday)

We will try to accommodate individual schedules as much as possible, please indicate which daily sessions would work best for your Student.

Access Information

Since programs will be entirely virtual, Students will need consistent access to a device that can connect to the online classroom site Moodle (such as a computer, tablet, or phone) and will need to be able to comfortably type their work (computer or tablet recommended). Will your Student need to borrow a device? *

Yes - Student needs to borrow a device

No - Student already has access to a device

Unsure - more details are needed

Does student need assistance to access a consistent internet connection? *

Yes - Student needs access to Internet Hot Spot

No - Student has consistent internet access

Unsure - more details are needed

Parent/Guardian 1 Information

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Parent/Guardian 1 Address *

Parent/Guardian 1 City *

Parent/Guardian 1 State/Province *

Parent/Guardian 1 Zip Code *

Parent/Guardian 1 Country

Is Parent/Guardian 1 the student's primary residence? *

Yes

No

Parent/Guardian 1 Best Phone *

(000) 000-0000

Parent/Guardian 1 Email *

Please provide an email you use regularly.

Parent 2 Information

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Address

Parent/Guardian 2 City

Parent/Guardian 2 State/Province

Parent/Guardian 2 Zip Code

Parent/Guardian 2 Country

Is Parent/Guardian 2 the student's primary residence?

Yes

No

Parent/Guardian 2 Best Phone

(000) 000-0000

Parent/Guardian 2 Email

Emergency Information

Additional Non-Parent Guardian Emergency Contact First Name *

In the event of emergency, Parents/Guardians will be contacted FIRST. Please provide a NON-Parent/Guardian Emergency Contact

Additional Non-Parent Guardian Emergency Contact Last Name *

In the event of emergency, Parents/Guardians will be contacted FIRST. Please provide a NON-Parent/Guardian Emergency Contact

Relationship to Student *

Emergency Contact Best Phone *

(000) 000-0000

Other Information

Health Information

Please let us know of any Health information that we may need to be aware of while engaged with your student.

Special Information

RAWK involves working in large and small groups, one-on-one interactions, giving and receiving feedback, reading aloud, and active listening. Please provide us with any special information you feel would help us create a safe and supportive environment for your student.

Media Release *

Yes

No

I permit Read and Write Kalamazoo to take photographs, audio, and video recording of my student for the explicit purpose of chronicling, promoting, and celebrating the RAWK program. I understand that any media taken of my student taken during RAWK programming will not be used by anyone not affiliated with Read and Write Kalamazoo.

Reserve My Spot *

I agree to notify RAWK as soon as possible if I am no longer able to attend so that the spot may be offered to another student

There are a limited number of spots available in each workshop. By completing this registration a spot will be reserved. If the workshop is already full, this registration will place you on the Wait List.

Data Collection & Reporting

We strive to serve our diverse community. Please share more about your family to help us assess and improve our community connection as well as report information anonymously to funders. This information will be kept completely confidential.

How does Student identify in terms of ethnicity and/or race?

Does Household qualify for Free or Reduced Lunch?

Yes

No

Workshop Registration

Student Information

Camp Information

Access Information

Parent/Guardian 1 Information

Parent 2 Information

Emergency Information

Other Information

Data Collection & Reporting

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