About Us
The Red Zone Executive Board
The Red Zone Youngstown Staff
The Red Zone Columbus Staff
Services
Events
Blog
Careers
Columbus—Mental Health Clinical Director
Columbus—Mental Health Clinician
Columbus—QMHS - Qualified Mental Health Specialist
Youngstown—Mental Health Clinician
Youngstown—QMHS - Qualified Mental Health Specialist
Contact
About Us
The Red Zone Executive Board
The Red Zone Youngstown Staff
The Red Zone Columbus Staff
Services
Events
Blog
Careers
Columbus—Mental Health Clinical Director
Columbus—Mental Health Clinician
Columbus—QMHS - Qualified Mental Health Specialist
Youngstown—Mental Health Clinician
Youngstown—QMHS - Qualified Mental Health Specialist
Contact
Your Youth's Information
Completing this form secures your child a spot into our program. Registration fees are due within 7 days to secure your child's slot in the program.
Youth's First Name:
Please type your full name.
Youth's Last Name:
Please type your full name.
Youth's Gender:
Male
Female
Please specify your position in the company
Youth's Birth Date:
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Youth's Age:
Please type your full name.
Youth's T-Shirt Size:
Select
Small (Child)
Medium (Child)
Large (Child)
XL (Child)
Small (Adult)
Medium (Adult)
Large (Adult)
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Please List Any Youth's Allergies:
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Please List Any Youth's Medications:
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Do you give us permission to administer medication?
Yes
No
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Who Will Administer Medication?
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Choose the Summer Enrichment week that your youth wants to participate in:
Select Summer Enrichment Week
Summer Enrichment (Week 1) June 11 to 15, 2018
Summer Enrichment (Week 2) June 18 to 22, 2018
Summer Enrichment (Week 3) June 25 to 29, 2018
Summer Enrichment (Week 4) July 2 to 6, 2018
Summer Enrichment (Week 5) July 9 to 13, 2018
Summer Enrichment (Week 6) July 16 to 20, 2018
Summer Enrichment (Week 7) July 23 to 27, 2018
Summer Enrichment (Week 8) July 30 to 3, 2018
Summer Enrichment (Week 9) Aug 6 to 10, 2018
Summer Enrichment (Week 10) Aug 13 to 17, 2018
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What REDZONE Program Will Attendee Participate In?
Select The REDZONE Summer Enrichment Program
Athletic Program (*Reserved for The REDZONE Clients)
Arts and Culture (*Reserved for The REDZONE Clients)
Young Adult Program (*Reserved for The REDZONE Clients)
PASSPORT TO FUN—THE RED ZONE PROGRAM
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Are you/child currently enrolled in The REDZONE?
Yes
No
Please specify your position in the company
If not, do you or your child need an assessment?
Yes
No
Please specify your position in the company
Parent/Guardian Contact Information
(1) Parent/Guardian First Name:
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(1) Parent/Guardian Last Name:
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(1) Parent/Guardian Home Phone:
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(1) Parent/Guardian Cell Phone:
Please type your full name.
(1) Parent/Guardian Email:
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(1) Parent/Guardian Birth Date:
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(1) Parent/Guardian Occupation:
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(1) Parent/Guardian Address:
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(1) Parent/Guardian City:
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(1) Parent/Guardian State:
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(1) Parent/Guardian Postal / Zip Code:
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(1) Parent/Guardian Employer:
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(1) Parent/Guardian Employer Address:
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(1) Parent/Guardian Employer Phone:
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Second (2nd) Parent/Guardian? Click Here
Second (2nd) Parent/Guardian? Click Here
(2) Parent/Guardian First Name:
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(2) Parent/Guardian Last Name:
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(2) Parent/Guardian Home Phone:
Please type your full name.
(2) Parent/Guardian Cell Phone:
Please type your full name.
(2) Parent/Guardian Email:
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(2) Parent/Guardian Address (*If different from address above):
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(2) Parent/Guardian Birth Date:
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(2) Parent/Guardian Employer:
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(2) Parent/Guardian Employer Address:
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(2) Parent/Guardian Employer Phone:
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Will you be making a Co-Payment?
Yes
No
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Emergency Contact Information
Name of Emergency Contact:
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Relationship to Participating Youth:
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Emergency Home Phone:
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Emergency Work Phone:
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Signature and Submit
I acknowledge with the submission of this form that I am agreeing to pay a $20 NON REFUNDABLE registration fee for my child to be enrolled in the Champions Summer Enrichment Program. I understand that my child's spot will not be secured until this fee is paid.
Signature:
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