| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Password must contain the following:
  • 12 Characters
  • 1 Uppercase letter
  • 1 Lowercase letter
  • 1 Number
  • 1 Special character
Booker T. Dozier Recreation Center
After School and Summer Program

Student Information



















2nd Student Information















3rd Student Information














Parent/Guardian Info















2nd Parent/Guardian Info














Sign-Offs and Consent

P A R E N T / L E G A L G U A R D I A N C O N S E N T A N D A U T H O R I Z A T I O N S

This program receives funding from the State of Michigan to serve your child. Michigan State University and Public Policy Associates are contracted to evaluate program quality and impacts. By enrolling my child in this program, I agree that the program will share the asterisked * attendance and demographic information with the contracted evaluators. All data will be kept confidential.




Parent Handbook Consent

I (the understated) agree that I have received the  After-School and Summer Parent Handbook. I agree to follow and abide by the policies and procedures outlined in the handbook. I understand that it is my responsibility to read and know all of the policies and procedures outlined within this handbook. If I have any question(s) I will ask the Program Site Manager.


General Release of Liability

I understand that program ends at the time specified in the handbook Monday-Thursday. Furthermore, I acknowledge that my child will be required to sign himself/herself out of the program at the end of program. Wayne Metro CAA, City of Inkster and We Rise staff and their partners or affiliates will not be responsible for students picked up late from the program. Three late pick ups will result in student being dropped from the program.


Medical Treatment Consent

I certify that my child is not suffering from any condition, physical, or otherwise that may prevent him/her from participating in any planned activity. If a medical emergency should arise regarding my child, I hereby grant Wayne Metro CAA/City of Inkster/We Rise permission to select a physician and/or hospital for my child’s care and to administer any emergency medical treatment which my child may require. I also give medical personnel and/or the hospital my permission to treat my child at the request of representatives of Wayne Metro CAA/City of Inkster/We Rise. I will assume responsibility for my child’s health while in the program. Should any above stated health condition change, I will promptly notify the Site Manager. I grant permission for my child(ren) to participate in all After School and Summer Program activities. The program staff and those operating the After School and Summer Program are authorized to consent to emergency medical treatment, if the need arises while this child is in the program. I agree to pay all costs incurred to provide such medical care. I have listed medical information important in treating this child on the registration form. I understand that Wayne Metro CAA/City of Inkster/We Rise, their officers, representatives, and employees, whether voluntary or employed, assume no responsibility whatsoever for any injury suffered by or medical emergency occurring to this child in the course of the program. I hereby release, exonerate, and discharge Wayne Metro CAA/City of Inkster/We Rise and its officers, representatives, and employees, from any and all liability, damages, actions or causes of actions for any injuries suffered by or medical emergency occurring to this/these children while enrolled in the After School or Summer Program.


Written Information Packet Documentation
A written information packet has been provided at the time of enrollment. The packet included all the following information:
  • Criteria for admission and withdrawal.
  • Schedule of operation, denoting hours, days, and holidays during which the center is open and services are provided.
  • Fee policy.
  • Discipline policy.
  • Food service program.
  • Program philosophy.
  • Typical daily routine.
  • Parent notification plan for accidents, injuries, incidents, illnesses.
  • Exclusion policy for child illnesses.
  • Notice of the availability of the center’s licensing notebook
○ The licensing notebook contains all the licensing inspection and special investigation reports and related corrective action plans since May 28, 2010.
○ The licensing notebook is available to parents during regular business hours.
○ Licensing inspection and special investigation reports from at least the past two years are available on the child care licensing website at www.michigan.gov/michildcare.

I certify that I received all of the above items.

Statement of child(ren)'s health and immunizations (rule 1809)
I state that my child(ren) is:
  • free from health conditions which could pose a risk to other children or adults,
  • has no limitations or special needs regarding participation in daily activities.
  • has a health or handicapping condition which could pose a risk to my child in care and I have attached a statement indicating the
  • limits of participation and any special needs or treatment while in care.
My child(ren) has completed or is in progress of receiving immunizations and booster as recommended by the Department of Community Health.
If NO, specify reason:
I certify that my child’s immunization record or the appropriate waiver is on file with my child's school and is up to date.

Field Trip Transportation

I hereby give my permission to: The Wayne Metro and/or We Rise for my child(ren) to walk or be transported in a vehicle and participate in field trips. I realize that I will be given a separate permission slip and information prior to each field trip that must be signed and returned for my child to participate.

Media Release

I give permission for photographs and/or video to be taken of my child for program newsletters, program publications, news media, etc

Movies

I give permission for my student to view G and PG rated movies shown for the purpose of education or entertainment.

Child Information Record

State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

For Provider Use Only:


Student Information










Parent/Guardian Information















2nd Parent/Guardian Information














2nd Parent/Guardian Information










Health/Physician Information





(Attach additional sheets, if necessary.)
Emergency Contact & Release of Child
Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)










Release of Child Only
Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)








Parent/Legal Guardian Initials

I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form








LARA is an equal opportunity employer/program.

AUTHORITY: 1973 PA 116
COMPLETION: Required
PENALTY: Rule Violation
CCL-3731 (Rev. 3/17/2022) Previous editions 7-18 & 4-21 may be used
Save my progress and resume later | Resume a previously saved form