STEAM Youth Program Registration Form for In Person Classes
Alliance for Lifelong Learning
Four Ways to Register: 1. Online - oakton.edu/youth 2. Mail - Alliance for Lifelong Learning, P.O. Box 367, Skokie, IL 60077 3. In Person - Skokie campus, Room A120; Des Plaines campus, Room 1170 4. Fax - 847.635.1448 Register for virtual classes at https://blackrocket.com/online/oak
Student and Parent Information (Please Print)
Student Name (First, Last)
Student Date of Birth
Parent Name (First, Last)
Phone
Emergency Phone
Street Address
City
State/Zip
Demographic Information of Student (This information is requested solely to comply with Federal laws)
1. Are you Hispanic or Latino? (OR Are you of Spanish origin?) □ Yes Hispanic or Latino. □ Not Hispanic or Latino. 2. Are you from one or more of the following racial groups? (Select all that apply). □ American Indian or Alaska Native □ Asian □ Black or African American □ Native Hawaiian or Other Pacific Islander □ White □ Choose Not to Respond 3. Please identify your primary racial/ethnic group. (Select one). □ American Indian or Alaska Native □ Asian
□ Black or African American
□ Hispanic or Latino
□ Native Hawaiian or Other Pacific Islander
□ White
□ Choose Not to Respond
4. Are you in the United States on a Visa – Nonresident Alien? □ Yes in the United States on a Visa. □ Not in the United States on a Visa. Provide Home Country of Origin: ___________________________________________
Method of Payment
□ Cash □ Discover Credit Card Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Exp. Date ___ ___ /___ ___ ___ ___ Three-Digit Verification Code (on back of card) ___ ___ ___ Cardholder Name (print) ___________________________________________________________ Cardholder Signature ____________________________________________________________ □ Check No. ____________________________________ (payable to Oakton College) □ Visa □ MasterCard Information and Consent Age Recommendations and Lunch: If your child’s age is just under or over 8 to 14, please contact us at 847.982.9888 for special consideration. Lunch is not provided. Students should bring their own lunch and snacks. Full-day programs will break for lunch at noon. Students registered for a half-day morning and afternoon program on the same day will be supervised by a staff member during the lunch hour between programs. Photo Release: Oakton College may use images of participants in the youth program for promotional and educational purposes. Please initial if you do not grant permission for possible photos and video to be taken of your child participating in the program. Initial ___________ Activity Agreement: The undersigned further agrees to forever release and discharge the college, its officers, agents, trustees, and employees against all claims for losses, damages, judgments, expenses, and liabilities which the undersigned or participant may have as a result of participation in the activity. In case of a medical emergency during the course of the activity, the undersigned hereby authorizes any local hospital, doctor, licensed medical practitioner, or emergency personnel, to take whatever action necessary to address the medical emergency. The undersigned certifies that the participant has health insurance coverage and the agrees that in the event medical treatment is rendered, said insurance shall be considered primary. If any provision of the agreement or part thereof is ruled unenforceable by a court of competent jurisdiction, the remainder of the agreement shall be in full force and effect. I have read, understand, and agree to the above. COVID-19 Protocols: Your health and safety is our top priority. We will continue to work closely with health officials and will implement further Covid-related restrictions as necessary. Information is subject to change. Visit www.oakton.edu/return for the most up-to-date information or email questions to coronavirus@oakton.edu . For more information regarding tuition, fees, cancelation and refund policies, visit www.oakton.edu/conted/tuition_fees.
______________________________________________________________________
______________________________________________________________________
_______________________
Parent Name (First, Last)
Parent Signature
Date
Continue on reverse side to select your courses and complete your registration.
STEAM YOUTH PROGRAM oakton.edu/youth 15
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