Roses In Concrete SC Youth Registration Form
Roses In Concrete is tailored for current 5th graders through current 10th graders in Charleston, Berkeley and Dorchester counties.
Email address *
Roses In Concrete Logo
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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DD
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YYYY
Address *
Your answer
City *
Your answer
County *
Required
State *
Your answer
Zip *
Your answer
Phone Number *
Your answer
Parent/Guardian Name *
Your answer
Relationship *
Your answer
Parent/Guardian Cell Phone *
Your answer
Parent/Guardian Home Phone *
Your answer
Please list any other important information (Special Needs, learning disabilities, EBD, person(s) not allowed to contact youth, specific behavioral patterns, important medical information, allergies, etc.) *
Your answer
RIC Youth Participant Safety Agreement
The safety of Youth Participants is of the utmost importance. Please know that that all Youth Participants must be escorted in and out of RIC upon arrival and departure. Participants will not be allowed to leave with any person not identified on the form. If alternative pick up arrangements have to be made, a written request must be provided upon arrival.
Person(s) Allowed to pick up youth - Name *
Your answer
Person(s) Allowed to pick up youth - Relation *
Your answer
Person(s) Allowed to pick up youth - Phone Number *
Your answer
Person(s) Allowed to pick up youth - Name
Your answer
Person(s) Allowed to pick up youth - Relation
Your answer
Person(s) Allowed to pick up youth - Phone Number
Your answer
Person(s) Allowed to pick up youth - Name
Your answer
Person(s) Allowed to pick up youth - Relation
Your answer
Person(s) Allowed to pick up youth - Phone Number
Your answer
Parent/Guardian Signature *
Your answer
Date of Submission *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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