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Naperville youth club
Virtual after school program
Registration-Permission Form 2020-2021

Student’s Name*
Gender*
- Male
- Female
Student’s Date of Birth*
MM slash DD slash YYYY
Student’s Age*
Ethnicity (Optional)
Grade*
Student’s School*
Student’s Email Address*
Name of Parent(s)/Guardian(s)*
Mailing Address:*
Home Phone Number*
Work Number*
Cell Number*
Email Address*
Emergency Contacts
Name
Phone Number
Relationship
Name
Phone Number
Relationship
In order to participate in virtual after-school, you will need to provide:
- A Zoom compatible device (computer, tablet, smartphone) with audio and video always on
- Current email address to receive video meeting invitations
- Current phone numbers of parent/guardian and student that staff can use to coordinate meetings
- Appropriate attire and decorum
Parental Consent for Zoom Virtual Tutoring
Naperville Youth Club (NYC) will provide a virtual after-school program using web-based Zoom as the video platform. NYC’s tutorial staff will monitor student activity on this platform and adhere to Zoom’s safety and privacy standards. As the Parent/Guardian of the above student, I give my permission for my child’s participation in this distance-based online tutoring program. I also agree to allow release of my child’s grades from his/her school to monitor success in this program.
I give my consent:*
- Yes
- No
Need submit /apply and payment options here.
Registration Fee
Price: