2023-2024 Registration Form

Participant first name *

Participant last name *

Participant street address *

Participant street address line 2

City *

Participant's birthday (mm.dd.yyyy) *

Participant's current grade *

6th grade

7th grade

8th grade

other

Participant phone number

Participant's email

Registering parent/guardian's first name *

Registering parent/guardian's last name *

My home address is the same as the participant's

Registering parent/guardian's home address if different from participant

Registering parent/guardian's email address

Registering parent/guardian phone number *

Emergency contact name (someone besides the registering adult) *

Emergency contact daytime phone *

MAD Club

is open to girls in grades 6-8

and operates

Monday-Thursday 2:45-5:30

400 E. Third St.

in the MAD Club building across the parking lot from

Elk Rapids Bible Church

(the church behind of the high school soccer field)

Please indicate with a check you have read and understand the items below *

MAD Club is a drop-in program. I understand if my daughter leaves the program early, she cannot return that day, unless arrangements have been made with staff

I understand while staff can work with me, they cannot monitor all rides. I will coordinate with my daughter regarding transportation and communicate with staff if there are special situations.

I understand MAD Club is a phone-free program. Phones will be placed in a safe place during MAD Club. Participants can have access to them if needed.

My daughter can leave the program on her own (walking, biking, etc) *

Yes

Does the participant have any allergies (food or other) we should be aware of? If none, enter "none" *

Does the participant have any medical conditions we should be aware of? If none, enter "none" *

Is the participant taking any medication(s)? If she needs to take it during MAD Club hours of operation, please provide instructions. Can she take this medication on her own? If so, does she need to be reminded? Does she need help? Does it need to be refrigerated? If none, enter "none" *

Is there anything else we should know?

Studies show healthy recreational options and encouraging homework settings improve school performance, behavior and relational skills. We have worked with local mental health and counseling professionals to develop a simple before-and-after questionnaire to measure changes in those areas for MAD Club participants. We would iike to gather "before-and-after" input from participants and parents. The information collected and the results will be completely anonymous.

My daughter can participate in this study *

Yes

I will participate in this study *

Yes

Right Tree programs have always been available on a donation basis. MAD Club is the same.

IF you have the ability to contribute, it is appreciated.

IF you have the ability to sponsor additional participants, it is REALLY, REALLY appreciated.

But what is the most appreciated is having your daughter attend, regardless of your ability to pay.

The program costs us $6.25 per day ($25/week; $100/month) to operate, per person. Please let us know below if you can help cover those costs and how you would like to pay.

This information is strictly confidential

I can contribute $6.25 /day ($25/week; $100/month) for my daughter's participation. *

yes

OR I can contribute this much per day for my daughter's participation. Please write "0" if none. *

I would also like to sponsor this many additional girls at $6.25/day ($25/week; $100/month)

OR I would like to make a single donation for this much right now to help sponsor additional girls.

I would like to pay *

with cash

with check - made out to Right Tree

with a credit card

this doesn't apply to me

I would like my additional sponsorship(s) to be

added to the method I use for my daughter

paid in a lump sum weekly

paid in a lump sum monthly

it's a one-time donation

I have questions, please contact me

I would like to *

receive a reminder each WEEK with the amount based on my daughter's participation

receive a reminder each MONTH with the amount based on my daughter's participation

have my credit card automatically charged each WEEK based on my daughter's participation

have my credit card automatically charged each MONTH based on my daughter's participation

I have questions, please contact me

This doesn't apply to me

If you are paying by credit card, please provide the following information

Credit card number

Expiration date (mm/yy)

Security code

Billing zip

I recognize that certain hazards and dangers are inherent with Right Tree [the parent organization of MAD Club] activities and programs and particularly, but not limited to recreational activities and competitions, the use of recreational equipment, hand and power tools, and being transported by Right Tree staff and volunteers in corporate or personal vehicles. I acknowledge that although Right Tree has taken safety measures to minimize the risk to injury to participants, Right Tree cannot ensure nor guarantee that the equipment, premises, and/or activites will be free from hazards, accidents, and/or injuries. I further recognize the importance of the above named minor child knowing and abiding by the program's rules, regulations, and procedures for the safety of activity participants. I recognize any child may be asked to leave the program at the discretion of the program staff. In consideration of Right Tree, accepting and permitting the above named minor child to attend this program and participate in activities, I agree that Right Tree, a non-profit corporation, its agents, officers, employees, trustees and volunteers wil not be liable for any injury, death, damage and/or loss to me, the above named minor child, and/or anyone claiming on my or my child's behalf, and I will further agree to hold harmless, indemnify and defend Right Tree, its officers, agents, employees, trustees and volunteers for and from any and all damage during the time the above named minor child is a participant. I certify that any and all photography, videotape and digital images of the above named minor child participating in Right Tree programs are the sole property of Right Tree and give permission for them to be used, without compensation, at the sole discretion of Right Tree. By signing below I certify I am the parent or legal guardian named above for the minor child named above and I give my permission for said child to participate in Right Tree programs. I also certify I am under no mental or legal disability, which would prevent me from signing and executing this agreement. I further represent that I have read (or have had read to me) and understand the terms of this agreement.

Driver's license or MI ID number (requested to help insure girls aren't registering themselves) *

Today's date (mm/dd/yy) *

Signature of parent/guardian completing this form -- sign with mouse or finger *

clear

After you press the "submit" button below you will receive an acknowledgment message

if this form is still on your screen after pressing the button, it was not sent.

Items still needing to be completed will be highlighted in red

Right Tree

P.O. Box 544, Elk Rapids, MI. 49629

(231) 668-8220

right.tree19@gmail.com

www.righttree.org

HELPING GIRLS DISCOVER THEIR WORTH, THEIR GIFTS, THEIR VOICE AND THEIR FUTURE

Right Tree is a tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code

Contributions are deductible as allowed by law