Name: Alternative Spring Break 2025
Start: 2025-03-24T08:30:00-04:00
End: 2025-03-27T12:30:00-04:00
Location: Eastland Middle School

Alternative Spring Break 2025

Parent/Guardian Information

Parent/Guardian Name*

Parent/Guardian Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Email Address*

May we send mail to your address?*

Yes
No

May we call you?*

Yes
No

May we leave messages on your phone?*

Yes
No

May we send email to your email address?*

Yes
No

How did you hear about our Alternative Spring Break?

Has you child/children participated in CARE's Leadership Camp/Alternative Spring Break before?*

Yes
No

Child's Name*

Child's Date of Birth*

School Name and District*

Grade in 2024-2025 School Year*

Does your child have difficulty making/keeping friends?*

Yes
No

Does your child have difficulty managing anger?*

Yes
No

Does your child have trouble staying focused?*

Yes
No

Are there any learning disabilities, physical disabilities, health concerns, or mental health concerns?*

Yes
No

Please list

Is your child attending counseling/ support groups*

Yes
No

List all medications your child is taking?*

Put N/A if does not apply

List all allergies (food, medication and animals):*

Put N/A if does not apply

Tell us a few of your child's strengths and postive qualities?*

Child 2 (if registering multiple children)

Child's Name

Child's Date of Birth

School Name and District

Grade in 2024-2025 School Year

Does your child have difficulty making/keeping friends?

Yes
No

Does your child have difficulty managing anger?

Yes
No

Does your child have trouble staying focused?

Yes
No

Are there any learning disabilities, physical disabilities, health concerns, or mental health concerns?

Yes
No

Please list

Is your child attending counseling/ support groups

Yes
No

List all medications your child is taking?

Put N/A if does not apply

List all allergies (food, medication and animals):

Put N/A if does not apply

Tell us a few of your child's strengths and postive qualities?

Child 3 (if registering multiple children)

Child's Name

Child's Date of Birth

School Name and District

Grade in 2024-2025 School Year

Does your child have difficulty making/keeping friends?

Yes
No

Does your child have difficulty managing anger?

Yes
No

Does your child have trouble staying focused?

Yes
No

Are there any learning disabilities, physical disabilities, health concerns, or mental health concerns?

Yes
No

Please list

Is your child attending counseling/ support groups

Yes
No

List all medications your child is taking?

Put N/A if does not apply

List all allergies (food, medication and animals):

Put N/A if does not apply

Tell us a few of your child's strengths and postive qualities?

Transportation

I give my child permission to:*

Walk home
Be picked up by myself (parent/guardian)
Be picked up by other adult

If picked up by other adult, please include their information below.

Information of other adult given permission to pick up your child/children (other than yourself)

Name

Relationship to Child

Phone

Email Address

Emergency Contacts (Please Provide 2)

Emergency Contact 1 - Name*

Emergency Contact 1 - Relationship to Child*

Emergency Contact 1 - Phone Number*

Emergency Contact 2 - Name*

Emergency Contact 2 - Relationship to Child*

Emergency Contact 2 - Phone Number*

Social Media and Photo Consent

Social Media Release*

Parent/Guardian by typing your name below you grant CARE of Southeastern Michigan the absolute and irrevocable right and unrestricted permission concerning the use of photographs that may be taken which may include with others, to use, reuse, publish, the photographs in whole or in part, individually or in connection with other materials. I release and discharge photographer from any and all claims that may arise out of or in connection with the use of the photographs, including without limitation any and all claims for liable or violation of any right of publicity or privacy.

Yes
No

Participating Consent

Parent/Guardian by typing your name below you give permission for my child to participate in the Care of Southeastern Michigan Leadership Academy. I give permission for my child/children to participate in the Care of Southeastern Michigan Leadership Academy. I understand the significance and importance of this program and I will take an active role in this experience and will support my child's understanding of the concepts and ideas it presents. I understand that my child will be required to complete a pre/post evaluation for the camp and that the purpose of this evaluation is to help CARE staff demonstrate that the program is effective and impactful for the participating youth. I also understand that CARE of Southeastern Michigan staff are mandated reporters and should there be concerns of neglect, abuse, or harm to others, CARE staff will be required to report these concerns. CARE of Southeastern Michigan reserves the right to remove youth should they not be an appropriate fit for camp. If CARE staff suspects that the person designated to pick up my child is under the influence of intoxicated, an alternative ride home must be identified.

Parent/Caregiver Signature*

Please type full name as this electronic signature will serve as your consent.

Today's Date*

Alternative Spring Break 2025

Details

Venue

March 24 – March 27