CAN Educational Program Registration Form 2022-23

Program Information: After School Program is grades K-12, Monday through Thursday, September-May, 4-6pm and Summer Camp is rising 1st through 6th, June 27 through August 4, 2022 on Monday through Thursday. Most camps are 10am-4:30pm, but times will vary by location.                                                           

Welcome!
Community Action Network (CAN) is a nonprofit organization in Washtenaw County dedicated to partnering with children, youth, and families to create brighter futures. We operate educational, stabilization, and community-building programs. 

This registration form is for families who would like to register their children for our high-quality educational programs! Learn more about each program at www.canwashtenaw.org/education.
Completing the form below does not guarantee your child or children are registered (due to a variety of factors). 

Once this form is reviewed, you will receive a notification from the relevant community center's staff with more program details or an explanation as to why your child or children have not been enrolled.

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This registration form contains the following:
  • General Household & Primary Caregiver Information
  • Emergency Contact Information
For each child/dependent:
  • Child General Information
  • Consent for Disclosure
  • Field Trip / Off-Campus Activity Permission Waiver
For entire household:
  • Client Rights & Responsibilities Waiver
  • Liability Waiver
  • Media/Photo Release Form (optional)
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Demographic information is requested for grant-writing/funding purposes so we can continue to provide FREE programs for children & youth and allows us to better support your child/children within our programs.
Getting Started
Caregivers can:
  • Fill out this form independently,
  • Call a CAN team member and fill it out together over the phone, or
  • Set up an appointment to fill the form out in-person at a CAN Community Center
Contact information for each community center is below.

While it is possible to complete this form on a mobile device, it will be easier to complete it on a desktop/laptop computer. CAN has computers connected to the Internet available at each community center for those who would like to come in and use one.
Community Action Network Location Information


If you do not fall within these eligible zones, you may not qualify for CAN's Educational Programs. Please contact (734) 994-2985 if you would like more information.
Primary Caregiver Information
New Households or if starting with a blank form: Please complete the information for yourself or the primary caregiver of the children being registered.

Existing Families: The individual's contact information that auto-fills into this form is who we have marked as the "Primary Parent/Guardian" in our records.  To update who your Household's Primary Parent/Guardian is, please contact CAN at (734) 994-2985 ext. 109 or klampen@canwashtenaw.org.

Please review and update information if something auto-filled incorrectly or if your information has recently changed.


















We will use the U.S. Census Bureau language for "Race" and "Ethnicity." If interested in reading more about how "Race" and "Ethnicity" are defined in this context, you may click to view this website: https://www.census.gov/newsroom/blogs/random-samplings/2021/08/measuring-racial-ethnic-diversity-2020-census.html



"Hispanic" refers to individuals who are Spanish-speaking or have a background in a Spanish-speaking country. Latinx/o/a refers to those who are from or have a background in a Latin American country (including those that are not Spanish-speaking)



Emergency Contact Information


Emergency Contact

Please provide an Emergency Contact (someone 18+ besides yourself) in case we cannot get in touch with you in an emergency.




I.e., They are on your rental or mortgage contract/agreement

Sample: 1234 Practice Lane, Ann Arbor, MI 48108
Insurance Information: By providing the information requested below, CAN staff accompanying your child to the ER or Urgent Care will be able to provide this information to healthcare providers if we cannot get a hold of you.


Start of Form for Child/Children
New Households or blank form:
Please complete the following information for each child/teen you are registering for CAN's After School Program and/or Educational Summer Camp.

For each additional child/teen, please select "Add another response" at the bottom of this section to add another child/teen.

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Existing Households or pre-filled form:
Details for anyone in our records as between the ages of 5-18 will appear automatically. Please review the pre-filled information to make sure it is accurate.

If we have an inaccurate Date of Birth, a student who should have appeared might not appear, or someone who isn't a qualified individual might appear even if you do not want to register them.

  • If someone auto-fills into the form that you do NOT want to register for an educational program or who does not qualify, please click the "Do not register this individual..." checkbox below and update their information to ensure we have accurate data on this individual.

  • If a student doesn't auto-fill that should have, please select "Add another response" to add another child/teen.
Student General Information
dProgram Information: After School Program is grades K-12, Monday through Thursday, September-May, 4-6pm and Summer Camp is rising 1st through 6th, June 27 through August 4, 2022 on Monday through Thursday. Most camps are 10am-4:30pm, but times will vary by location.
Program Registration


Example: Child is too old for Educational Summer Camp


Example: Child has other commitments and cannot participate on a daily basis












If no, type "None" or "N/A"

If no, type "None" or "N/A"

In the case of an emergency, if we have permission, we will take your child to seek proper medical care. It helps CAN staff accompanying your child/teen to have their doctor/dentist's name (or office name) and phone number in the case of an emergency. If possible, please provide the following:






We will use the U.S. Census Bureau language for "Race" and "Ethnicity." If interested in reading more about how "Race" and "Ethnicity" are defined in this context, you may click to view this website: https://www.census.gov/newsroom/blogs/random-samplings/2021/08/measuring-racial-ethnic-diversity-2020-census.html



"Hispanic" refers to individuals who are Spanish-speaking or have a background in a Spanish-speaking country. Latinx/o/a refers to those who are from or have a background in a Latin American country (including those that are not Spanish-speaking)
Consent for Disclosure
Purpose of the Disclosure: Educational Planning and Partnership.

Granting CAN & partnering schools access to the following information allows CAN Educational Program staff and interns the ability to partner with families and schools to ensure the best outcomes for our shared students.
  • CA-60 File
  • Academic Records
  • Attendance Records
  • Discipline Records
  • Special Education Records
  • Medical Records
  • Access to Schoology
  • Access to PowerSchool
  • CAN program related records

The school selected for this individual (above) is not responsible for the actions of the third party (Community Action Network) with respect to the use, maintenance, or confidentiality of the student education records disclosed pursuant to the caregiver consent provided herein. Further, I agree to release, indemnify, and hold harmless the listed school, its employees, officers, and agents, from all liability for damages of whatever kind which may result on account of the school's compliance, or any attempts to comply, with this authorization.

Community Action Network's Access to Records

Under this authorization, Community Action Network agrees that it shall not re-disclose information from education records without the prior written consent of the parent/guardian or as permitted by law. Community Action Network agrees that it shall destroy the records once they are no longer needed for the purpose of which they were disclosed.

Field Trip / Off-Campus Activity Permission Waiver
Sometimes Community Action Network coordinates field trips for students within After School Programs and Educational Summer Camps. Previous trips have been to local pools, the library, university/college campuses, Ann Arbor Hands On Museum, Leslie Science and Nature Center, Botanical Gardens, the Toledo Zoo, and more!


End of form for child

Select "Add Another Response" text to add another dependent to this registration form.

Household-Wide Consent (Caregiver + Dependents)
Client Rights & Responsibilities
Your rights as a CAN client include, but are not limited to:
  • Confidentiality of information

  • Privacy (including your consent or refusal over use of you and your child / children's photographs in informational and promotional materials)

  • Freedom from abuse, exploitation, retaliation, humiliation, and neglect

  • Timely receipts of information

  • Being treated with courtesy and respect

  • Access or referral to legal representation, self-help, and advocacy services

  • A prompt response by CAN for all communications

  • Informed consent or refusal and expression of choice regarding service delivery, concurrent services, staff assignment, and research involvement

  • Investigation and resolution of alleged infringement of rights without fear of reprisal
Your responsibilities as a CAN client include, but are not limited to:
  • Cooperation in the maintenance of a safe and confidential environment

  • Treat CAN staff members, volunteers, and other clients with courtesy and respect

  • Help to maintain a drug and alcohol-free environment

  • Attend scheduled appointments on time and cancel them in advance if necessary

  • Respond promptly to call communications from CAN

  • Complete all required paperwork promptly, thoroughly, and to the best of your availability
Non-Discrimination Statement: CAN complies with all federal, state, and local non-discrimination laws and ordinances by ensuring that no person be discriminated against (including employees, clients, and volunteers) in any employment, housing, or service delivery based on the person's actual or perceived race, color, age, gender, religion, national origin, physical or mental limitation, heigh and weight, marital status, family responsibilities, educational association, condition of pregnancy, source of income, sexual orientation, gender identity, or HIV status.

Complaint Process: As a client, you have the right to file a complaint with Community Action Network (CAN). CAN defines a complaint as any expression of concern about any inaction or action.
  • Possible subjects for complaints include, but are not limited to: the quality of programs and services provided, aspects of interpersonal relationships such as rudeness from an employee or volunteer with CAN, failure to respect your rights, or a disagreement with a decision that was made.
You may file a complain in the following ways:
  • Email: Please send an email with your complaint in writing to your closest community center director or to info@canwashtenaw.org
  • In-Person: Talk with one of the community center directors or ask them to provide a means for written feedback
  • US Mail: Please write your concern to: Community Action Network, PO Box 130076, Ann Arbor, MI 48113
However you file a complaint, always make sure it is in writing.

Following the receipt of a complaint, CAN will do the following:
  • Acknowledge the receipt of the complaint by contacting the client within two (2) weeks of the receipt of the complaint

  • Research and resolve the complaint within thirty (30) calendar days from the receipt of the complaint

  • Notify client of outcome

  • Provide interpreter services, if necessary

Liability Waiver
I acknowledge there are risks associated with my child/children's participation in Community Action Network (CAN)'s educational programs, but not limited to those associated with travel, transportation, or vehicular traffic, climate or weather or other natural phenomenon, accident, the child's own actions or the actions of others. I understand these risks may result in serious illness, injury, or death and hereby accept and assume, for my dependents, all such risks.

I give permission for my children to participate in the associated activities. I freely and voluntarily for my children, myself, my executors, administrators, heirs, next of kin, successors agree to:

  • Waive, release, and discharge from any and all liability, CAN and its board of directors, employees, and volunteers for my child's death, disability, personal injury, property damage, property theft, or actions of any kind which may thereafter occur to him, her, or them, including as to my child's travel to, from, and during any of these activities or trips.

  • Indemnify and hold harmless the organizers, its board of directors, employees, and volunteers from any and all liabilities or claims made by other individuals or entities as a result of or relating to my child/children's participation in these activities.

  • I further understand CAN is not and will not be responsible for any medical costs that may be incurred by my child.

Media/Photo Release (Optional)


Exempting an individual means you may want to give consent for most of your household members, but have a specific member you do NOT want included in the media/photo release.

You will be asked to sign with an e-signature on the following page after clicking "Submit".