After School/Summer Camp Enrollment Form

Afterschool / Summer Camp Enrollment Form

Welcome to Our
AfterSchool & Summer Camp Enrollment Page!

At Guided Grace Family & Youth Services, we are excited to provide engaging and enriching after-school and summer camp programs designed to support your child’s growth, learning, and well-being.

Complete the enrollment form below to secure your child’s spot and give them an experience filled with fun, learning, and meaningful connections.

Let’s get started!

Enrichment & Mindfulness Camp 2025 Enrollment Form

*Program Site Name:

Afterschool / Summer Camp Enrollment Form (2025)

School Time

First Ward (Saginaw)

Summer Time

First Ward (Saginaw)

Guided Grace FYS (Saginaw)

Heritage Youth (Detroit)

New Birth Missionary Baptism (Saginaw)

Please note First Ward is the only site we’re offering afterschool programming this year.

Student Information

Student Name:

Address(Required)

Address City ZIP / Postal Code

Phone Number(Required)

Date(Required)

MM slash DD slash YYYY

School Name(Required)

Grade Level(Required)

Gender

Gender(Required)

Male

Female

Nonbinary / Some other gender

Prefer not to disclose

Race / Ethnicity(Required)

American Indian / Alaskan Native

Asian

Black/ African American

Hispanic/ Latino

Middle Eastern/ North African

Native Hawaiian / Pacific Islander

White

Perfer not to disclose

Transportation Home(Required)

Pickup/ Drive

Walk

Bus

Other

Are Siblings Enrolled?(Required)

Yes

Siblings Names(Required)

First Last

School Contact Information
(For Teacher Survey)

Contact Name(Required)

Contact Name

Email(Required)

Contact Type(Required)

Teacher

Counselor

Parent / Legal Guardian
Contact Information

Parent / Guardian 1

Parent / Guardian 2

Authorized Pickup 1

Authorized Pickup

Authorized Pickup 2

Authorized Pickup

Name (Parent Guardian 1)(Required)

Name

Name (Parent Guardian 2)(Required)

Name

Relationship to Camper (Parent Guiardian 2):(Required)

Relationship to Camper (Parent Guiardian 1):(Required)

Phone Number (Parent / Guardian 1)(Required)

Phone Number (Parent / Guardian 2)(Required)

Email (Parent / Guardian 1)(Required)

Email (Parent / Guardian 2)(Required)

Address (Parent / Guardian 1)(Required)

Address (Parent / Guardian 2)(Required)

Emergency Contacts
(Authorized for Pick Up If Needed)

Emergency Contact #1

Emergency Contact #2

Name (Emergency Contact 1)(Required)

Name

Name (Emergency Contact 2)(Required)

Name

Relationship to Student (Emergency Contact 1):(Required)

Relationship to Student (Emergency Contact 2):(Required)

Phone Number (Emergency Contact 1-1)(Required)

Phone Number (Emergency Contact 2-1)(Required)

Phone Number (Emergency Contact 1-2)(Required)

Phone Number (Emergency Contact 2-2)(Required)

Health and Medical Information:

Please Mark Below if Student Has Needs Related to:(Required)

Allergies

Asthma

Diabetes

Hearing Impairment

Heart Troubles

Learning Disabilities

Physical Limitations

Seizures

Vision Problems

Other

(Check all that apply):

Food Allergies:(Required)

Allergic to Bees?(Required)

Yes

I Don’t Know

Any other health concerns we should know about?(Required)

Name and Phone Number of Campers physician / health clinic(Required)

Preferred Hospital for Medical Treatment:(Required)

Parent / Legal Guardian Consent and Authorizations

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.

Read each statement and mark the circle to indicate agreement:

Read each statement and mark the circle to indicate agreement:(Required)

Enrollment in the program is voluntary. I understand that regular attendance is expected.

I have received a copy of the family handbook. I agree to the program’s policies. I will tell the program if my contact information changes.

I understand that the program’s playground equipment may not fully comply with licensing standards.

I give my permission for my child to attend field trips. Program staff will give me information about the field trips in advance. I agree that the program is not responsible if my child has a medical emergency during a field trip.

I have told the staff about any restrictions to my child’s activities

My child’s immunizations records are up to date. I agree to provide the immunization record or appropriate waiver with the program upon request.

If my child needs medication during the program, I will give the site manager (a) a medication authorization form and (b) the medication in its original prescription bottle.

I give the staff permission to get emergency medical treatment for my child. Emergency treatment may include surgery.

I give the staff permission to apply insect repellent, sunscreen, and antibacterial cleanser to my child’s skin when needed. I can ask for specific information about these products.

Student’s Name:(Required)

Student’s Name:

Parent/ Guardian Name:(Required)

Parent/ Guardian Name:

Date: (mm/dd/yyyy)(Required)

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Afterschool / Summer Camp

Guided Grace 9-12

1232 N. Michigan Ave
Saginaw

Building Blocks Childcare K-5

1310 N. Michigan Ave.
Saginaw

LongLong Art Studio K-8

1909 Livernois Rd.
Troy

New Birth Missionary Baptist Church K-8

3121 Sheridan Ave.
Saginaw

Christ Image Community Church K-5

5501 Gratiot Rd.
Saginaw

Wee Care Christian Childrens K-5

1605 Amanda Dr.
Saginaw

Afterschool / Summer Camp Enrollment Form

Welcome to Our AfterSchool & Summer Camp Enrollment Page!

Enrichment & Mindfulness Camp 2025 Enrollment Form

*Program Site Name:

Afterschool / Summer Camp Enrollment Form (2025)

Student Information

Gender

School Contact Information(For Teacher Survey)

Parent / Legal GuardianContact Information

Parent / Guardian 1

Parent / Guardian 2

Emergency Contacts(Authorized for Pick Up If Needed)

Emergency Contact #1

Emergency Contact #2

Health and Medical Information:

Parent / Legal Guardian Consent and Authorizations

Read each statement and mark the circle to indicate agreement:

Afterschool / Summer Camp

Guided Grace 9-12

Building Blocks Childcare K-5

LongLong Art Studio K-8

New Birth Missionary Baptist Church K-8

Christ Image Community Church K-5

Wee Care Christian Childrens K-5

Welcome to Our
AfterSchool & Summer Camp Enrollment Page!

School Contact Information
(For Teacher Survey)

Parent / Legal Guardian
Contact Information

Emergency Contacts
(Authorized for Pick Up If Needed)