Membership Enrollment Form 

Any information requested on this form is used for recording purposes or required for funding.
The answers you provide on this membership form will be kept CONFIDENTIAL

Please select which program(s) you would like your child to attend. Please note that for summer programs an additional application will need to be completed for file.
Participant Information
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
School Information
School Address *
School Address
Teacher's Name
Teacher's Name
Parent Information
Parent Name *
Parent Name
Address *
Address
Phone *
Phone
Work Phone Number *
Work Phone Number
Medical and Emergency Contact Information
Physician Address
Physician Address
Physician Phone
Physician Phone
Date of Last Physical *
Date of Last Physical
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Address *
Emergency Contact Address
Phone *
Phone
Financial
Check All That Apply *
How did you hear about us?
Check all that apply *
Note to Parent
Youth participation in Diamonds On The Rise programs is likely to produce positive outcomes when youth engage in more than one of our programs and consistent with services. Diamonds On The Rise staff welcomes high levels of youth participation in all programs as well as special programming
Participation Agreement
I have read and spoke with staff about polices and procedures of the organization and have completed the application. I understand the rules of Diamonds On The Rise and request that my son/daughter/ward be admitted into the program. I have explained the rules to my son/daughter/ward and agree that Diamonds On The Rise will not be responsible for any accident to the boy/girl while on the Diamonds On The Rise premises or while engaged in any of its activities away from Diamonds On The Rise. I understand and agree that my child (or ward) must be picked up by closing time or a fee will be charged. Fees must be paid before the child can attend the next session. I give my consent for photographs or videoing taping in which my son/daughter/ward may appear, to be used in any way the Diamonds On The Rise may care to use them as long as it is consistent with the Diamonds On The Rise mission. By submitting this form, you consent to all above rules and permissions. We look forward to working with you and your child!