Coming of Age Program Application Join the next generation of successful youth
*Application deadline is April 16, 2024
If you need a scholarship please call (617)-459-1029
Note: This form is to be completed by the child’s parent/guardian. The Coming of Age program will not sell or transmit your information to third parties for unrelated purposes. The information provided below will be kept confidential by the Coming of Age program unless it is legally required to provide it to third parties or unless the Coming of Age program has entered into arrangements with third parties to assist in providing your child with the program services for which you are applying. With regards to medical or health insurance information, Coming of Age program shall use or disclose this information only as it reasonably is determined necessary to safely provide programming to your child or to obtain emergency medical care for your child.
Parent/Authorized Guardian Contact Information
Parent/Guardian #1
Parent/Guardian #2
Alternative Authorized Guardian Authorized to pick up child?
Medical Contact Information
Applicant's Health Information A. Allergies (check those that apply and detail the specific nature of allergic reaction – e.g., difficulty breathing, hives, rash).
Does your child carry an EpiPen or epinephrine autoinjector in the event of an allergic reaction? *
B. Other significant health conditions (check those that apply):
Does your child use an inhaler?
Does your child use insulin?
Please explain any items that are checked “Yes” or "Other". Indicate any information useful in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted or accommodations that may be necessary to allow your child to participate meaningfully in the program. The Coming of Age program reserves the right to request a health form from the child’s physician clearing the child to participate in anticipated program activities.
Type explanation here.
C. If your child takes any medication regularly, please understand the Coming of Age program can’t be responsible for administering any medication. Please make arrangement to give the child the medication before or after the 2.5-hour program.
Emergency Contact In case of an emergency, I understand that every effort will be made to first contact the parents/guardians listed above and then any Emergency Contact(s) designated below.
In the event efforts to reach a parent/guardian or authorized mergency contact in a timely manner are unsuccessful, I hereby give permission to the Coming of Age program to secure proper treatment for my child, as needed as directed by emergency personnel.
If the parent(s)/guardian(s) cannot be reached in an emergency, please contact the individual(s), if any, listed below who are authorized by virtue of my signature below to make decisions about emergency care until a parent/guardian can be reached.
Parent/Guardian Commitments The Coming-of-Age program is run by South Shore Caribbean Connection, a nonprofit organization. The program will run four (4) weeks. At the end of the program, we would like to honor the children with a dinner. There will be a small cost of $15 per ticket for the dinner to help cover the cost. The program will meet at The Randolph Intergenerational Community Center at 128 Pleasant Street in Randolph, MA.
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Your signature below represents your acknowledgement and agreement that:
1. You grant permission for your daughter/son to participate in the program and will be present at all 4 workshops to get the best possible results.
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2. You will encourage your daughter/son to participate in all meetings with her/his peers and other program activities. You will support these activities by inquiring of your daughter/son as to what takes place in the program. If you have any questions or concerns, please call or text 617-249-3860 (preferred) or email me at sscc@southshorecaribbeanconnection.com
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3. You will support your daughter's/son's participation by providing transportation or arranging for transportation to/from sessions.
4. I authorize the Coming of Age program or its representatives to take photographs & video of my child in connection with her/his participation in the above-referenced program. I authorize the Coming of Age program to use and publish the photos and/or video in print and/or electronicially. I agree that the Coming of Age program may use such photographs & video of my child with or without my child’s name and for any lawful purpose, including for example, but not limited to, such purposes as publicity, illustration, advertising, web content and end of program scrapbook.
5. You acknowledge that as part of the Coming of Age programming your daughter/son may be participating in physical activities (such as dancing or working with their hands) that can be physically challenging.
6. In consideration for allowing my child to participate in activities provided, hosted, sponsored by or otherwise affiliated with or connected to the Coming of Age program (the “Activities”), You agree to hold harmless the Coming of Age program and any of its staff members or volunteers, officers, directors and trustees and program partner organizations and their respective volunteers, officers, directors and trustees from and against all injuries, causes of action, suits, liabilities, losses, proceedings, damages, demands, claims, fees and expenses, present or future, whether known or unknown, anticipated or unanticipated, which may be incident to, or arise out of, by reason of, or in connection with your daughter’s/son’s participation in the program.
I have discussed the program activities with my daughter/son and am confident that she/he has the maturity and ability to participate in this program.
Program Expectation:
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There is a $50 fee to sign up for the program.
Students are required to be at all 4 workshops to get an opportunity to earn $25.00 per w orkshop.
To earn the $25.00 for each workshop, students may be given some self-building homework and required to do one age-appropriate community service project.
Go to Checkout
Thanks for submitting! You will be directed to pay your fee.
