2022-23 DEPOT PROGRAM REGISTRATION
Contact Information
Student First Name *
Student Last Name *
Student Cell Phone *
Student Email *
School
Darien High School Middlesex Middle School Fitch Academy Darien Public Elementary Private Other
Birth Date *
Gender
Female
Male
Non-binary/non-conforming
Prefer not to respond
Grade in 22-23 school year
5 6 7 8 9 10 11 12
PARENT/GUARDIAN *
Parent/Guardian Cell Phone *
Parent Email *
Address 1
City
State/Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip
Emergency Contact *
Emergency Contact Phone *
All students will receive a Depot t-shirt.
T-Shirt Size *
Youth M
Youth L
Adult XL
Adult L
Adult M
Adult S
Adult XS
Adult XXL
DEMOGRAPHICS
We collect the following information to include in grants that go towards funding Depot programs. Your name will be kept confidential. Only your demographics will be provided. Thank you.
Free/Reduced Lunch *
receives free/reduced lunch eligible for free/reduced lunch not eligible for free/reduced lunch
Ethnicity *
Hispanic/Latino Not Hispanic/Latino
Family *
2 Birth/Adoptive Parents Step and Birth Parent Single Parent Female Single Parent Male Grandparents DCF Foster Parents On Own Other
Annual Household Income *
<$25,000 $25,000-$50,000 $50,000-$100,000 $100,000-$150,000 $150,000 +
Members In Household
Family of 2 Family of 3 Family of 4 Family of 5 Family of 6+
PROGRAM REGISTRATION
There is an annual $75 membership fee to participate at the Depot, this includes a Depot t-shirt. Please check the box next to the program(s) you would like to participate in below. Scholarship assistance is available, please contact: john@dariendepot.com. No Refunds.
Commitment Policy: By signing here, I understand I am only allowed 3 absences throughout the year. If I exceed this amount, I understand I will be dismissed from the program. All Depot programs run from September-May.
Program Registration Fee *
Program Fee $75
Student Signature *
High School Programs
2022-2023 High School Depot Programs
Life Skills Club Volunteer Club Respect Works Helping Hands/Paws SADD-HS Girl’s Night Out (GNO) SLOD Smiles for Seniors
Middle School Programs
2022-2023 Middle School Programs
Intro to High School Weird Science Leadership Club Garden Club-Session #4 Garden Club-Session #5 7th Grade Choose Love Drop Zone Friday Night Friends
5th Grade Programs
PERMISSION AND EMERGENCY/MEDICAL/COVID INFORMATION
Allergies/Medical Conditions
In case of emergency, if I cannot be reached, I give permission to the attending physician to hospitalize, secure necessary treatment, order injections, anesthesia, or surgery for my child named on this form. Additionally, I, the undersigned, do hereby waive and hold THE DEPOT YOUTH CENTER, its employees and agents, harmless from any personal or property damage I or my child may incur while participating in activities at THE DEPOT YOUTH CENTER. I also understand THE DEPOT YOUTH CENTER does not provide accident or health insurance. In addition, I give permission for my child to participate in all programs at THE DEPOT YOUTH CENTER.
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19. The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.Noroton Heights Depot, Inc. (The Depot Youth Center) has put in place preventive measures to reduce the spread of COVID-19; however, The Depot Youth Center cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending The Depot could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the clubs and programs offered by The Depot Youth Center, and that such from the actions, omissions, or negligence of myself and others, including, but not limited to, Depot employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, buy not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at The Depot or participation in Club programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless The Depot, it’s employees, agents, and representatives, of and from Claims, including liabilities, claims, actions, damages, costs or expense of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of The Depot., it’s employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Depot program.
Parent Signature *
THE DEPOT NEEDS YOUR HELP! PARENT INVOLVEMENT OPPORTUNITIES
The Depot Board of Directors encourages Depot parents to contribute their time and talent to The Depot in some way. Our success, depends on the commitment of many. Please check one of the boxes below if you are interested in lending a hand. We will contact you with further details. Thank you!
