register my child

Contact Form

Please Read: This form is the general contact form to enroll your child into programs. Once we receive the contact information you will be contacted to tour the Dream Center and fill out additional paperwork so that we may be better able to serve your child. Currently we have a waiting list for our students. Your child will be put on the waiting list after you complete this documentation. Once there is room for your child to join, you will be contacted by the Dream Center to set up a parent meeting and introduce you to programs. Thank you!

Mother/Guardian: *

First

Last

Father/Guardian: *

First

Last

* Indicates required field

Address *

Line 1

Line 2

City

State

Zip Code

Country

Child *

First

Last

Gender *

Birthday *

Grade *

Please select your child's current grade.

School *

Home Phone *

Cell Phone *

Work Phone *

Email *

High School District *

Senior High School Hempstead High School Wahlert High School

Does your child receive free or reduced lunch? *

Yes No

I would like to be a part of the parent committee *

Yes No

My child can walk home *

Yes No

Does your child need transportation from school to the Dream Center? *

Yes No

My child can be transported to the Dream Center from School *

Yes No

I will be picking my child up from programs *

Yes No

Medical Release History

Health Statement: (to be completed by Parent/Guardian and/or Medical Doctor). YES responses will require and explanation.

Respiratory problems – Asthma, persistent cough, etc. *

yes no

Heart problems – High/low blood pressure, chest pain, etc. *

yes no

Kidney, stomach, Gall Bladder or Liver problems *

yes no

Diabetes, hypoglycemia *

yes no

Recent fractures, illness, exposure to contagious disease, etc. *

yes no

Choose OneEye, ear, nose or throat problems – Skin disease *

yes no

Allergies – Bee stings, ant bites, plants, sun, food, penicillin, etc *

yes no

Emotional disorders – Frequent anxiety, excessive fears, etc. *

yes no

Any hospitalization in the last two years? *

yes no

Does your child have any physically limiting conditions? *

yes no

Does your child currently take medication? *

yes no

The participant WILL be bringing medication to programs and activities *

yes no

If you answered yes to any of the above questions please explain: *

Emergency Medical Treatment: I understand that every effort will be made to contact the parent(s) or guardian (s) of participants. If this is not possible, I hereby Authorize the Dubuque Dream Center to obtain medical treatment.

Parent/Guardian Signature *

First

Last

Father has authorization to remove child *

yes no

If Not please explain: *

Mother has authorization to remove child *

yes no

If Not please explain: *

Other has authorization to remove child *

First

Last

Phone Number *

Other has authorization to remove child *

First

Last

Phone Number *

Comment *

Conflict Resolution

Heath & Nutrition:
Basketball Players must be excellent athletes. Stretching before practices, games, etc. is mandatory. Players must demonstrate the coordination, athleticism, and flexibility, which is necessary in basketball.
An injury must be reported to the coach immediately. The coach must approve an absence from practice, game, etc. due to a player attending an appointment with a personal physician, in advance. If an injury or illness incapacitates a player, they will not be permitted to practice or play for a period of time as determined by their physician and the coach.
Good nutritional habits are encouraged throughout the season. Coaches should provide encouragement and guidance.

Player Attendance Policy.
*Coaches are to be notified in advance of any absences or if participant is to be late

Conflict Resolution:
Parents – Please respect the coaches for their decisions. A coachs’ decision is not questionable.  Please don’t coach your child from the sideline during the game. If you have an issue, speak to the coach at an appropriate time.
Player issues are to be directed to the head coach of a team. They are to be resolved at a non-game situation (i.e. before or after practice if coach approves, separate scheduled meeting, etc). Players are encouraged to speak with the coach themselves, then, if necessary, the parents should contact the coach. If resolution cannot be attained in this manner, a meeting with all necessary parties may be called if deemed necessary.
Remember: Coaches and parents are facilitators in making this a productive and enjoyable experience. All of the above Procedures, Policies, and guidelines are subject to revisions or changes.
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I have read, understand, and agree to comply with the Dubuque Dream Center Intensity Policies (see below submit button) and Procedures as stated. I understand that my child will be put on the waiting list for programs, and I will be contacted by the Dream Center once there is an opening.

I give my child permission to participate in the Dubuque Dream Center Intensity and other programs. I also give permission for my child to be photographed or recorded for program promotion and fundraising purposes. With that acceptance, I agree to abide by the rules and obligations stated in the Policy and Parent Pledge. My signature below means that I agree to the above.

Intensity Parent Signature *

First

Last

Intensity Player Signature *

First

Last

Dream Center Basketball Policies
File Size:	325 kb
File Type:	pdf

Dream Center Volleyball Policies
File Size:	192 kb
File Type:	pdf

Contact Form

Medical Release History

Conflict Resolution

Location

The Dubuque Dream Center

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