After-school & summer camp

Enroll with
Guided Grace FYS

Complete your student’s enrollment information and permissions below.

Fields marked Required must be completed. Insurance information and card uploads are optional. You can submit your enrollment without them. Submitting an application does not confirm a space; our team will follow up.

*Program Site Name:

Program Site Name

Building Blocks Childcare – 1310 N. Michigan Ave Saginaw, MI 48602

Guided Grace FYS – 1232 N. Michigan Ave. Saginaw, MI 48602

New Birth Missionary Baptist – 3121 Sheridan Ave, Saginaw, MI 48601

Weecare Early Learning Center – 1605 Amanda Dr, Saginaw, MI 48638

Student Information

Student Name:

Address(Required)

Phone Number(Required)

Date(Required)

Phone Number(Required)

Grade Level(Required)

Teachers Name:(Required)

Teacher’s Email:(Required)

Student’s Primary Language:

English

Spanish

Other

T-Shirt Size:

Youth

Adult

Youth T-Shirt Size:

Small

Medium

Large

Adult T-Shirt Size:

Small

Medium

Large

Gender

Male

Female

Nonbinary / Some other gender

Prefer not to disclose

Race / Ethnicity

American Indian / Alaskan Native

Asian

Black/ African American

Hispanic/ Latino

Middle Eastern/ North African

Native Hawaiian / Pacific Islander

White

Perfer not to disclose

Check all that apply)

Transportation Home

Pickup/ Drive

Walk

Bus

Other

Are Siblings Enrolled?

Yes

Siblings Names

First Last

Parent / Legal GuardianContact Information

Parent / Guardian 1

Parent / Guardian 2

Authorized Pickup 1

Authorized Pickup

Authorized Pickup 2

Authorized Pickup

Name (Parent Guardian 1)

Name (Parent Guardian 2)

Relationship to Camper (Parent Guiardian 2):

Relationship to Camper (Parent Guiardian 1):

Phone Number (Parent / Guardian 1)

Phone Number (Parent / Guardian 2)

Email (Parent / Guardian 1)

Email (Parent / Guardian 2)

Same Address as Child?

Yes

Same Address as Child? (2)

Yes

Address (Parent / Guardian 1)(Required)

Address (Parent / Guardian 2)

Zip Code: (Parent / Guardian 1)

Zip Code: (Parent / Guardian 2)

Emergency Contacts(Authorized for Pick Up If Needed)

Emergency Contact #1

Emergency Contact #2

Name (Emergency Contact 1)(Required)

Name (Emergency Contact 2)(Required)

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

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

Phone Number (Emergency Contact 1)(Required)

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

Health and Medical Information:

In the event of a medical emergency, what is the hospital preferred for Medical Treatment:

Please Mark Below if Student Has Needs Related to

(Check all that apply):

Other:

Food Allergies:

Allergic to Bees?

Yes

I Don’t Know

If medication is to be distributed during the program, I understand that a medication authorization form must be on file with the program leadership _______ (initials) and it is my responsibility to make sure the leadership has the authorized medication to be administered in a timely manner _____(initials)

Please describe any special instructions/information that may be useful for staff to know:

Parent / Legal Guardian Consent and Authorizations

**Please read the statement below and check the box next to each statement **

Emergency Medical Treatment: I give Permission to the program staff (licensed by the state of Michigan) to secure medical and/or surgical treatment for the above(Required)

Yes

Family Handbook: I have received a copy of the family handbook. I agree to the program’s policies.(Required)

Yes

Immunization Records: My Child’s immunization records are up-to-date. The immunization record or appropriate waiver is on file with the program. My child is in good health with activity restrictions noted(Required)

Yes

Contact Information: I agree to contact the program leadership at my site if my contact information changes(Required)

Yes

Field Trip: I hereby give my permission for my student to attend field trips. I understand that information will be provided prior to every field trip. I agree to accept all medical responsibility in the case of emergency due to accident or illness(Required)

Yes

Topical Application Waiver: I give the staff permission to apply insect repellent, sunscreen, and Neosporin wound cleanser when appropriate. I understand that specific product information is available upon my request from the program leadership team.(Required)

Yes

Program Enrollment: I understand that enrollment in this program is voluntary. In order to assure that each student makes the desired progress for academic success, I understand that regular attendance is expected.(Required)

Yes

Permission to Photograph: I give my permission that photos/videos taken of my youth during camp activities on any given day can be legally used in agency specific publications, publicity, illustrations, copyright purposes, and advertising. I also agree and legally consent to the use of photos/videos on the corporate website for marketing and educational purposes. Furthermore, I understand that no royalty or compensation shall become payable to me by reason of such use.(Required)

Yes

Guided Grace FYS Group Services

As part of the Out-of-School Time (OST) program, Guided Grace will be delivering therapeutic group sessions and enrichment activities. Guided Grace is the service provider working in partnership with Guided Grace Family & Youth Services (GGFYS) to ensure high-quality, supportive programming for all enrolled youth. Insurance information is optional. You can enroll even if your child does not have insurance or you do not have the information available. If provided, insurance information helps Guided Grace coordinate care and, if applicable, manage billing for group sessions.

Primary Insurance Plan:(Optional)

Policy Number:(Optional)

Group Number:(Optional)

Secondary Insurance (if applicable):

Policy Number:

Group Number:

If available, you may attach photos of the front and back of your child’s insurance card below. Insurance details and card copies are optional and do not prevent enrollment. Please note that all information will be kept confidential and used solely for the purposes of coordinating care and services. By Signing my student up, I authorize this program to collect and use data about my child for the purposes of program development, safety, and improving educational outcomes. I understand that this data will be kept confidential, stored securely, and used by authorized personnel within the organization, and shared with Michigan Department of LifeLong Education, Advancement and Potential (MiLEAP) 32n OST Grants Program and state evaluation partners.

Insurance card photos or documents (Optional)

Add the front and back now using photos from your phone or saved files. Choose up to 2 files, 8 MB each. JPG, PNG, WebP, HEIC, HEIF, or PDF.

Choose card photos or files

No files selected.

Files are sent with your enrollment when you select Submit enrollment. You can leave this section blank.

Parent/ Guardian Name:(Required)

Parent/ Guardian Signature:(Required)

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