Change Makers Enrollment Form

Choose A Program *

Mommy, Daddy and Me
"Black Girls Code" Coding Camp
Technovation Girls
Come Get Your Books
Solar Camp
Making Me
Money Matters

Child's Name *

First

Last

Birthday *//

Child's Gender *

Child's School Grade *

Address *

Address Line 1

City

State

Zip Code

Child's School *

With whom is child living?

Mother's Name *

First

Last

Father's Name *

First

Last

Legal Guardian's Name *

First

Last

This Person's Name *

First

Last

Address (If Different From Child's)

Address Line 1

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone

Email Address *

EMERGENCY CONTACT IF PARENTS CANNOT BE REACHED *

First

Last

Relation To Child *

Home Phone *

Work Phone

Cell Phone

Child's Name *

PARENT/GUARDIAN CONSENT AND RELEASE: I grant my permission for my child to participate in the Detroit Impact Center Programs including all on-site and field trip activities. The Detroit Impact Center and those operating programs are authorized to consent to emergency medical treatment while this child is in the Detroit Impact Program. I hereby release, exonerate, and discharge Detroit Impact, Inc. and its officers, directors, representatives, employees, whether voluntary or employed from any and all liability, damages, actions, or causes of action for any injuries suffered by or medical emergency occurring to this child while enrolled in the Detroit Impact Program. In addition, I understand and agree that Detroit Impact and its officers or representatives will and are hereby authorized to make audio and/or video recordings of the program activities and to incorporate these recordings into public relations and advertising materials or otherwise and to license others to do the same in any manner of media whatsoever. *

I agree to the above consent and release

Parent/Guardian Initials *

Date *

ChangeMakers Enrollment Form