2026 Registration New Participant

2026 Program Registration
Medical Information
Physician Name
Office/Clinic Name
Phone Number
Allergies/Medical Conditions
(please type None if there are none)
Current Medication
(please type None if there are none)
Dietary Restrictions
(please type None if there are none)
Emergency Contacts
Please list all emergency contacts
Household Information
Language(s) spoken at home
Internet access at home
Total household size
(number of persons living in house of student)
Other family members participating in Rodney Street programs
Total household income level
Family Information
(1) Parent/Guardian

First NameLast Name
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email

Confirmation Emailexample@example.com
Employer
Occupation
Work Phone Number

Area CodePhone Number
(2) Parent/Guardian

First NameLast Name
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email

Confirmation Emailexample@example.com
Address (please change if different from first page)

Street Address

Street Address Line 2

CityState

Zip Code
Employer
Occupation
Work Phone Number

Area CodePhone Number

2026 Program Registration
Parental Consent
Parent Initials
Please select consent given below and sign.

I grant RodneyStreet unrestricted permission to use photographs and/or video and/or voice recordings taken of my child for use in RodneyStreet publications, including web sites or other electronic forms of media. I authorize RodneyStreet, its assigns, and transferees to copyright, use, and publish the same in print and/or electronically. I agree that RodneyStreet may use such photographs of my child, with or without my child’s name, and for any lawful purpose, including, but not limited to, publicity and Web content.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Communications Consent
I understand that as part of the registration process, either one or both parent/guardians listed in this application will be automatically enrolled to receive RodneyStreet communications. This includes the Remind App (a text based service) that will be used by staff for program communications and emails that will include the RodneyStreet monthly newsletter and general organization informational emails. You have the option below to not automatically receive the monthly newsletter.