Steps to Success Registration Form
Sign in to Google to save your progress. Learn more
Email *
Student First and Last Name *
Student Number (Lunch Number) *
Grade (2023 - 2024) school year *
Race *
Gender *
School (2023 - 2024) school year *
 Address *
Need Transportation *
Parent Name *
Parent Phone Number  *
How many other children in your household? *
How many adults in your household? *
Emergency Contact 1 
Emergency Contact 1 Phone
Comments (Allergies, etc.)

BY Submitting this Registration Form: I GIVE CONSENT TO THE FOLLOWING

1. My child is registering to Attend Steps to Success Saturday and Summer Program with Epps Christian Center and any field trips with the program.  Necessary Precautions and supervision will be provided.  The Epps Christian Center and Escambia Children's Trust (ECT) will not be responsible for any injury that may occur during the program or lost or stolen items.

2. I Give Permission for Program Staff to Obtain and review my child’s academic and behavior reports from his/her school, including grades, attendance, discipline reports, and standardized test scores.  This includes information about whether my child has an identified exceptionality, an individual education plan (IEP) or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the Program.

3. Program Staff May Use photographs/videos in which my child or I may Appear for program or ECT publicity, press releases, news stories, and other such purposes

4. Program Staff May Calculate Health information on my child such as weight and  bmi  (Body Mass Index) for grant objectives (pre, mid and post)

5. My Child Will Maintain attendance standards (at least 2 Saturdays a month and 3 days/week during the summer program).  Failure to maintain attendance standards will result in termination from the program.

6. I understand that Respectful and Cooperative Behavior is Expected, I will ensure that my child follows Behavior.

7. I Understand that in the event of a medical emergency, every effort will be made to contact me.  If I cannot be Reached, I give Permission to secure the services of a licensed physician.

Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy