Kareem youth program forms

Child Information

Child’s Full Name *

Date of Birth *

Age *

Current Grade Level

School Currently Attending

Allergies (Food/Environmental)

Medical Conditions

Behavioral / Emotional Considerations (if applicable)

Parent / Guardian Information

Parent/Guardian Name *

Relationship to Child *

Primary Phone *

Secondary Phone

Email Address *

Home Address *

Emergency Contacts (Required - Two)

Emergency Contact #1: Name *

Emergency Contact #1: Relationship *

Emergency Contact #1: Phone *

Emergency Contact #2: Name *

Emergency Contact #2: Relationship *

Emergency Contact #2: Phone *

Authorized Pickup & Release Authorization

List all individuals authorized to pick up your child:

The Kareem Center will only release my child to the individuals listed above unless otherwise authorized in writing.

Authorized Pickup Person #1 (Name / Relationship / Phone) *

Authorized Pickup Person #2 (Name / Relationship / Phone)

Authorized Pickup Person #3 (Name / Relationship / Phone)

Parent Initials *

Custody / Legal Restrictions

If yes, documentation must be provided prior to participation.

Are there any custody agreements, restraining orders, or legal restrictions regarding who may pick up this child? *

Parent Initials *

Program Selection (Check all that apply)

Program Selection (Check all that apply) *Summer Leadership CampCharacter & Confidence WorkshopsYouth Enrichment SessionsSeasonal Break CampsLeadership & Personal Development CohortsSpecial Topic Workshops (Entrepreneurship, Public Speaking, etc.)Other

Other

Participation & Behavior Expectations

The Kareem Center is a structured youth development environment focused on leadership, character building, confidence, and positive peer engagement. Respectful participation and adherence to program expectations are required.

Parent/Guardian Initials *

Student Code of Conduct

Students must treat peers, staff, and property with respect. Bullying, aggression, or disruptive behavior will not be tolerated. Students are expected to participate positively, follow staff instructions, and demonstrate accountability aligned with leadership development principles. Progressive discipline may include redirection, parent notification, temporary suspension, or dismissal if necessary.

Parent Initials *

Student Initials (age 8+)

Comprehensive Medical History & Health Profile

Other

Please explain any checked items in detail

Primary Physician Name & Phone (optional)

Medication Disclosure & Authorization

I authorize staff to administer prescribed and emergency medications as reasonably necessary to protect my child’s health and safety.

Does your child require or carry any medication? *

If yes, list medication(s) and purpose

Medication kept with

Parent Initials *

Emergency Medical Action Consent

In the event of a serious or life-threatening emergency, I authorize staff to take immediate action, including administering available emergency medication and contacting emergency medical services prior to reaching me if necessary.

Parent Initials *

Illness & Participation Readiness

I agree not to send my child to programs when they are ill, contagious, or physically unable to safely participate in scheduled activities.

Parent Initials *

Student Acknowledgment (Ages 8+)

I understand that The Kareem Center is a leadership and character development program. I agree to follow expectations, participate respectfully, and take responsibility for my behavior.

Student Name

Student Signature (type your full name)

Date

Parent Authorization & Final Consent

I understand that my child’s acknowledgment reflects their responsibility within the program. I retain full legal authority over enrollment decisions and participation approvals.

Parent/Guardian Name *

Parent/Guardian Signature (type your full name) *

Date *

Liability Waiver & Program Acknowledgment

I understand my child will participate in structured youth development activities including indoor and outdoor enrichment. I release The Kareem Center and its affiliates from liability for minor injuries occurring during normal program participation, except in cases of gross negligence.

Parent Initials *

Program Fit & Continued Participation

While enrollment opportunities are open, continued participation is based on program determination that the environment is an appropriate developmental fit. The Kareem Center may adjust placement or discontinue participation to preserve a positive experience for all students.

Parent Initials *

Youth program forms

Complete your Kareem Center forms online

Youth Program Intake & Participation Packet

Child Information

Parent / Guardian Information

Emergency Contacts (Required - Two)

Authorized Pickup & Release Authorization

Custody / Legal Restrictions

Program Selection (Check all that apply)

Participation & Behavior Expectations

Student Code of Conduct

Comprehensive Medical History & Health Profile

Medication Disclosure & Authorization

Emergency Medical Action Consent

Illness & Participation Readiness

Student Acknowledgment (Ages 8+)

Parent Authorization & Final Consent

Liability Waiver & Program Acknowledgment

Program Fit & Continued Participation