OZONE

Opportunity Zone Livingston County Middle School Youth Participant Registration Form
Last Name Ethnicity (check 1) Gender (check 1)

First Name Asian Female

Middle American Indian/Alaskan Native Male
Date of Birth ____/____/____ Grade Black (not of Hispanic origin) Primary Language (check 1)

Address Zip Hispanic English

Parent/Guardian Name Native Hawaiian or Other Pacific Islander Spanish

Work Phone White (not of Hispanic origin) Other (Specify)
Cell Phone Other (Specify) Lives With (check 1)
Relationship Restrictions Both Parents
Parent/Guardian Name Check if legal restrictions are in effect. List persons Foster Care
not allowed to see student at Site and/or persons not
Work Phone allowed to pick up students per legal restrictions. Grandparent(s)
Cell Phone First Name Last Name Joint Custody
Relationship Single parent Father
Additional Contacts: First Name Last Name Single parent Mother
List additional contacts for the child and use the check boxes to indicate if these individuals Other (Specify
are authorized to pick up the child and/or will serve as an emergency contact. Checking the
Lives with box indicates that the person listed is a member of the same household. If no First Name Last Name Special Needs:
adults are listed below, and if no boxes are checked, ONLY THE (i.e. allergies, medications,
PARENT(S)/GUARDIANS WILL be able to pick up the student. accessibilities, diet, etc.)
Name Name Name

Phone Number Phone Number Phone Number

Pick up Pick up Pick up

Emergency Contact Emergency Contact Emergency Contact
Lives With Student Lives With Student Lives With Student
 Parent/Guardian Permission for 21st Century CLC *Please Read Carefully*
Must be signed by Parent/Guardian for student participant 18 and under. If you have any questions, please
contact your 21st CCLC Director prior to completing the permission form.
I hereby give permission for the participant listed on this registration form to take part in the 21 st Century Community Learning
Center (CCLC) activities, which may include off-site events, field trips, academic assistance, continuing education, and
recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the
participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be
responsible for any transportation charges and medical expenses incurred. I agree that if a health condition exists now or in the
future which would impact the participation of the student listed on front, I will notify the 21st Century Community Learning Center
staff.
I give my consent to the School District and the 21st Century Community Learning Center (CCLC) program to take the
participants photograph during program activities, to be used for education and public relations purposes. I further give my
consent to the School District and the 21st Century Community Learning Center (CCLC) program to share the participants
student records with each other for purposes of providing educational support and assistance. In addition, I understand that the
21st Century Community Learning Center will use the participants records to evaluate individual progress and improvement, as
well as to evaluate the impact of the program on student achievement. The student data will also be used to fulfill the State and
Federal annual progress reporting requirements to obtain continued funding for the program.
I hereby certify that I have read and do understand the above information.
Signature Printed Name Date

Medical Release Information
Student Name Date of Birth Social Security Number

Allergies Medical Conditions

Health Insurance Carrier Policy # Group #

** Livingston County Board of Education furnishes the following school time insurance on each student enrolled in school. This insurance is
secondary if you have private insurance.
K&K Insurance Group, INC
1712 Magnavox Way
PO BOX 2338
Fort Wayne, Indiana 46801
(800)237-2917

___________________________ parent/guardian herein named gives Livingston County Board of Education employees permission to
seek medical treatment necessary for the student named above, in the event of injury during school or school-related trips.
Parent/Guardian Signature Relationship to Student Date

Parent/Guardian Daytime Phone # Alt Parent /Guardian Phone #

Additional Adult Contact Contact Phone #