Youth Registration | Thea Bowman Center

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Additional Info:

YOUTH AFTER SCHOOL AND SUMMER K-8TH GRADE REGISTRATION

To register, please take the time to fill out the information below.

YOUTH INFORMATION

First Name

Last Name

Age

DOB

Address

City

Zip Code

Child's last grade completed

Phone

School name

Ethnicity

Language

PRIMARY CAREGIVER INFORMATION

Primary Care Giver Relationship (check):

Mother

Father

Grandparent

Other

If other, please enter relationship to youth.

Primary Care Giver Name: First, Last

Telephone

Address

Education:

High School

Pursuing GED

Copy of Pursuing GED

Marital Status:

Single

Married

Widowed

Divorced

Employment Status

Employed

Unemployed

Disability

Secondary Caregiver (In case of emergency)

Secondary Care Giver Relationship (check):

Mother

Father

Grandparent

Other

If other, please enter relationship to youth.

Secondary Care Giver Name: First, Last

Address

Telephone

My Child has the following Medical Problems (include food allergies, medications etc.). Please explain

Brothers and Sisters Enrolled in the Program

PERMISSION TO PARTICIPATE IN Summer and After-School

The Thea Bowman Center provides summer and after school program for children K to 8th grade. Families/children must have access to a computer and Internet/Wi-Fi capability to participate in online. All families/children must participate in a mandatory orientation session for online with TBC center staff. By signing this form I (we) agree to the orientation session and will provide timely feedback information when requested. I give my child or children permission to participate in the online program. I understand the terms of participation.

Do you Understand?

Yes

I give permission for my child to participate in the Thea Bowman Center’s supervised After-School and Summer Program. Tutoring, Music, Kung- Fung, Field Trips, Black History and other learning activities .

Yes

PICTURES/STORIES: I will share pictures and stories of the program experience. I give TBC permission to use pictures and stories to promote TBC programs: brochures, web page, fund raising events, social media/Facebook.

Yes

I understand that youth (online and in person) program is presented, monitored and supervised by
trained Thea Bowman staff. Parents are expected to monitor and supervise the online activities of their
children. Children may participate in online and in person field trips and learning events of which
parents will know in advance. Please call 216 491 0699 or Sylvia Little-Harris

Thea Bowman Center

©2019 Thea Bowman Center | Thea Bowman Center is a 501 (c)(3). GED® is a registered trademark of the American Council on Education (ACE) and administered exclusively by GED® Testing Service LLC under license. For more information, visit: www.gedtestingservice.com.

Address:

11901 Oakfield Ave

(On the corner of E. 120th and Union)
Cleveland, OH 44105

T: 216-491-0699

F: 216-491-1678

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