CAN Educational Program Registration Form 2024-25

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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

Please select your nearest CAN location:

Arrowwood Hills
2566 Arrowwood Trail, Ann Arbor, MI 48105
(734) 389-7108
Eligible Families: Student/primary caregiver lives in the Arrowwood Hills Co-Op

Brick

8970 Whittaker Road, Ypsilanti, MI 48197

(734) 263-1629
Eligible Families: Students attend Brick Elementary

Bryant

3 W. Eden Court, Ann Arbor, MI 48108

(734) 477-0292

Eligible Families: Student/primary caregiver lives within or near the Bryant neighborhood & qualifies for Free & Reduced Lunch*
*Eligibility for this location may vary by case as some Washtenaw County residents outside of this zone may qualify. Please contact the center to learn more about your eligibility.

Creekside Court
3425 Platt Road, Ann Arbor, MI 48108
(734) 619-8031
Eligible Families: Student/primary caregiver lives in the Creekside Court neighborhoodGreen Baxter Court
1737 Green Road, Ann Arbor, MI 48105
(734) 622-9590

Eligible Families: Student/primary caregiver lives in the Green Baxter Court neighborhood

Hikone
2724 Hikone Drive, Ann Arbor, MI 48108
(734) 973-1183

Eligible Families: Student/primary caregiver lives in the Hikone neighborhood

Director Email Notification

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 or info@canwashtenaw.org.

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

Primary Contact ID

Primary Contact First Name (i.e. nickname, chosen name, preferred name, etc.)

Primary Contact Last Name

Primary Contact Legal Name (if different from above)

Primary Contact Date of Birth

Phone

Check all that apply: How do you prefer we contact you for program-related communications (program closures, reminders, etc.)?

TextPhone CallEmail

Street Address (including Apt/Unit # if applicable)

City

State

Postal/Zip Code

Does your household receive Free/Reduced Lunch?

YesNoUnknown

VBH: Does your household receive Free/Reduced Lunch?

YesNoUnknown

How many people live in your household?

Click here to opt out of the additional optional information below to help us collect data to fund our FREE programs for children & youth, and to help us better support you and your family.

Your information will only be used for general purposes to help us understand who we are partnering with and how we can better help each other.

Annual Household Income Range (before taxes):

Less than 20,00020,000-39,99940,000-59,99960,000-79,99980,000-99,999100,000-124,999125,000-149,999150,000+

Are you a single parent household?

YesNo

What languages do you speak?(check all that apply):

EnglishArabicSpanishMandarinOther

If "Other," you may share here:

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

Race (check all that apply):

American Indian or Native American / Alaska NativeAsian / Asian AmericanBlack / African AmericanNative Hawaiian / Other Pacific IslanderWhite / CaucasianPrefer not to sayOther

If "Other," you may share here:

Ethnicity:

Hispanic/LatinxNon-Hispanic/LatinxUnknownPrefer not to say"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)

Gender (check all that apply):

FemaleMaleTransgenderNon-binary/non-conformingPrefer to self-describePrefer not to say

Pronoun(s) (check all that apply):

SheHeTheyOther

If "Other," you may share here:

Emergency Contact Information

I give Community Action Network permission to take my child/children to the ER or Urgent Care in the case of an emergency:

YesNo

If "No," could you share why?

Emergency Contact

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

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Is this person a member of your household?

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

Emergency Contact Full Address

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.

Insurance Company (Medicaid, Blue Cross Blue Shield, etc.)

Insurance Policy Number or Member ID (Sample: XYZ000123456)

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

Program Registration

Youth First Name (i.e. nickname, chosen name, preferred name, etc.)

Youth Last Name

Youth Legal Name (if different from above)

Youth Contact ID

Youth Date of Birth

Youth Age

Educational Summer Camp (rising 1st-rising 6th)*:

Would you like to Enroll your child in summer camp?

EnrollDo Not Enroll*Brick is ONLY Rising 2nd-5th

Reason to not enroll:

Example: Child is too young for Brick's Educational Summer Camp

YouthWorks (Ages 14-18 by the start of the program):

Would you like to Enroll your teen (or yourself) in YouthWorks?

EnrollDo Not Enroll

Reason to not enroll:

Example: Child is too young for YouthWorks or Teen is unavailable to participate

YouthWorks Director Email

After School Program (K-12* in the upcoming school year):

Would you like to Enroll your child, youth, or teen in the After School Program?

EnrollDo Not Enroll*Exceptions to K-12 include: -Arrowwood Hills: K-8th -Brick: 2nd-5th

Reason to not enroll:

Example: Child is ineligible at CAN location

Youth Gender (check all that apply):

FemaleMaleTransgenderNon-binary/non-conformingPrefer to self-describePrefer not to say

Youth Pronoun(s) (check all that apply):

SheHeTheyOther

If "Other," please share here:

School

If "Other" school please indicate here:

Grade this child/teen will be in for the 2024-25 school year

IEP or 504 Plan?

IEP504 PlanNoneUnknown

Does this child/teen have any allergies we should be aware of?

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

Does this child/teen take any medication we should be aware of?

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

If this child/teen must take medication during summer our after-school programs, do we have permission to store and administer it?

YesNo, I'll make sure they receive their medication outside of programN/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:

Doctor Name and/or Name of Doctor Office

Doctor/Office Phone

Dentist Name and/or Name of Dentist Office

Dentist/Office Phone

Click here to opt out of the additional optional information below to help us collect data to fund our FREE programs for children & youth, and to help us better support you and your family.

Your information will only be used for general purposes to help us understand who we are partnering with and how we can better help each other.

Languages Spoken (check all that apply):

EnglishSpanishArabicMandarinOther

If "Other," you may share here:

Race (check all that apply):

American Indian or Native American / Alaska NativeAsian / Asian AmericanBlack / African AmericanNative Hawaiian / Other Pacific IslanderWhite / CaucasianPrefer not to sayOther

If "Other," you may share here:

Ethnicity:

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
IEP and 504 Plans
Academic Records
Attendance Records
Discipline Records
Special Education Records
Medical Records
Access to Schoology, PowerSchool, and other tools utilized by the school
CAN program related records

If there are additional records you would like released related to this student, or if you have questions or concerns, please share below:

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.

Consent for Disclosure

By checking this box, when I submit this form and sign on the following page, I hereby authorize my child's school to release their Education Record Information to Community Action Network as specified above.

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!

Field trip/off-campus activity permission

By checking this box, submitting this form, and signing on the following page, I give permission to include this child in the activities and trips coordinated by Community Action Network

If applicable, you are welcome to share questions or notes

YouthWorks

YouthWorks participants must also complete a W-9 and Work Permit per participant. Below are links to the PDF forms that you can download and print, the YouthWorks Program Director (Harrison at hmetzler@canwashtenaw.org/734-994-2985 Ext. 110) or Community Center Director can assist with downloading and completing these PDFs, or you can find the forms in your school's administrative office.

W-9 Form

State of Michigan CA Work Permit:
CA-6 Work Permit (14-15 years) - please print front and back
CA-7 Work Permit (16-17 years) - please print front and back

When these PDFs open, download them and save them to your computer or flash drive. We recommend that you print them blank and complete the paper versions. Please use the participant's information, not the parent/guardian's information when completing these forms. All forms must be completed with black ink ONLY or they will not be accepted.

Please indicate if CAN YouthWorks staff have permission to contact the YouthWorks participant (for program-related purposes ONLY) and share the participant's contact information below:

I give CAN YouthWorks staff permission to contact the YouthWorks participant for program-related purposes ONLY by the following means (Check ALL that apply):

Phone (text or call)Email

Participant's Phone Number:

Participant's Email:

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.

Filing a Complaint

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

Client Rights & Responsibilities

I understand and agree to the statements above

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.

Liability Waiver

I understand and agree to the statements above

Media/Photo Release (Optional)

By checking this box, submitting this form, and signing on the next page, I give consent on behalf of my dependents and myself to Community Action Network to use my child / children's and my name, photograph, portrait, and any likeness in any media form and type of publication, including newspaper articles, annual reports, newsletters, and social media. I grant CAN any and all rights to said use without compensation.

Optional: Please name any household members you would like exempted from this release:

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".

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Form Record ID

Household ID

Registration Sequence

Contact Information