MS 7th-8th Grade Registrations

Opportunity is missed by most people because it is dressed in overalls and looks like work.
-Robert Frost

A Program of

ONLINE PROGRAM REGISTRATION FORM

RASA, 420 Broadway, Rockland, ME 04841

For Middle School Students grades 5 - 7

* required fields

*Student Name:

*Mother/Guardian Name:	Father/Guardian Name:

*School:	*Grade:

*Home Phone:	Parent Cell:	Student Cell:

*Address

*City	*State	*Zipcode

*Grade:

*Date of Birth:

00/00/0000

*Gender:

F/M

We are going green! Receive registration information and updates by providing your email below.

Parent Email:	Student Email:

* Is this your first time participating in a RASA program? Yes No

*Returning/on-going participants:

Has your medical information changed since you last participated in RASA programs? If yes, we will send you a form to update your information.

Yes No

* I live with my: Mother Father Both Guardian Other

Race (optional): African American Asian Caucasian

Latino Native American Pacific Islander

Other (Please specify):

Medical Information and Emergency Contacts

Please list ALL medical conditions and allergies:

Please list ALL medications your child is currently taking:

Emergency Contact Information: (other than parent listed above)

	Relation	Name:	Phone:
*1.	Doctor:
2.
3.

Please sign up for programs below. Program space is limited. If you don't make it into an activity we will add you to the waiting list; we will call you if a space opens up.

Summer Camp Registration

Camp runs from 9am - noon unless otherwise noted.

Week	Track Selection
Week 1 6/25-6/29	Sailing 9AM-4PM
Week 2 7/2-7/6 No camp on 7/4	Bobcat	Moose	Fox
Week 3 7/9-7/13	Bobcat	Moose	Fox
Week 4 7/16-7/20	Bobcat	Moose	Fox
Week 5 7/23-7/27	Bobcat	Moose	Fox
No camp July 30 - August 17
Week 6 8/20-8/24	Sailing 9AM-4PM

*By typing my name below, I am agreeing to adhere to the expectations of RASA Programs which can be viewed here:

* Student Signature

* Date 00/00/0000

*By typing my name below, I give permission for my child to participate in the activities listed above:

* Parent/Guardian Signature