Summer Enrichment Online 2020 Registration
Program Dates: Monday, June 22nd thru Thursday, July 30th via ZOOM Platform
| CONTACT |
[Doreen Brant, South Lyon Area Youth Assistance Caseworker]
[Sue Collins-Schroeder, South Lyon Area Youth Assistance Secretary]
[Jenny Cort, Summer Enrichment Program Coordinator]
[Marcie Kryka, Summer Enrichment Program Director]
[Youth Assistance Website]
[Summer Enrichment Website]
Grade in Fall 2020
Elementary (My child is going into 1st-5th Grade)
Mid-High (My child is going into 6th-9th Grade)
Full Home Address
Primary Phone Number
Secondary Phone Number
Parent Email #1
Parent Email #2
Additional Emergency Contact(s)
Due to the nature of this year's program format, the agreed-upon session fee is a flat reduced rate of $10 per student. If you wish to contribute more in the form of voluntary donation, you may choose to do so. In this event, please contact the Youth Assistance office at (248) 573-8189 for additional information about charitable donation tax deductions.
Session fees can be paid via Youth Assistance's PayPal account page, located at the link below. Please include "SEP - [Student Name]" in the notes section on the payment page to ensure your fee is processed accordingly.
If you need to make separate arrangements for payment or would like to inquire about alternative payment options, please contact Doreen Brant or Sue Collins-Schroeder at the Youth Assistance office contact information listed at the top of this form.
Please use the PayPal "Donate" Button, which can be found on both the SLAYA page and the Summer Enrichment Registration page:
Virtual Consent and Release
I grant permission for my child to participate in the South Lyon Area Youth Assistance (SLAYA) Summer Enrichment Program and Summer Enrichment Online, including all on-site and off-site activities. SLAYA is authorized to consent to emergency medical treatment if the need arises while the child is in the program. I agree to pay all costs incurred to provide medical care. I understand that SLAYA, its officers, directors, agents, and representatives, and employees, whether voluntary or employed, assume no responsibility for any injury suffered by or medical emergency occurring to this child in the course of the program. On behalf of myself and this child and to the full extent permitted by law, I hereby release exonerate, and discharge SLAYA and its officers, directors, agents, representatives, and employees, whether voluntary or employed, for any and all liability, damages, actions, or causes of action for any injuries suffered by or medical emergency occurring to this child while enrolled in the program.
In addition, I understand and agree that SLAYA and/or its officers, directors, contractors, agents, and representatives will and are hereby authorized to make audio and/or video recordings, capture photographs, and edit footage of the Summer Program activities. On behalf of myself and this child, I hereby authorize SLAYA without payment to myself or on behalf of this child, to record this child’s picture, video, and voice on photographs, films, and tapes, to edit these recordings at its discretion, and to incorporate these recordings into movie and sound films, broadcasts programs, public relations and advertising materials, Facebook, Instagram, YouTube, Zoom, and additional social media platforms.
Digital Signature and Date
I hereby agree/consent to the above. In lieu of handwritten signature, I have provided my full typed name and date below.
Sign by Typing Full Name
Never submit passwords through Google Forms.
This form was created inside of Summer Enrichment Program.