TriCity Family Services

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Trek for 6th Graders - Helping your 6th grader address middle school challenges.

Date: Saturday, November 15, 2025

Time: 9:00 AM - 1:30 PM (Check-In 8:45 AM)

Location: Geneva Middle School South, 1415 Viking Drive, Geneva, IL 60134

Register your 6th grader below to participate in Trek for 6th Graders (with curriculum by Navigate Adolescence), brought to you by TriCity Family Services and the Geneva Coalition for Youth with the support of Geneva CUSD 304.

Please note that ONLY a parent/guardian of a Trek for 6th Graders participant may complete this registration due to the permission/waiver that is included.

Registration Fee for Trek for 6th Graders participants:
$20* per 6th Grader

Please complete your registration below. Once your transaction is complete,
you will receive a receipt via email.

*Need-based fee reductions are available for those who qualify.
To request a fee reduction, please email trek@tricityfamilyservices.org
to request a fee waiver code that must be used in this on-line registration.

Qty

Description

Amount

Total

Trek for 6th Graders Registration(s)

$20.00

---

per 6th Grader

CODE to REGISTER with an ALTERNATIVE FEE or SCHOLARSHIP

---

Total: $0.00

Participant #1 Information

6th Grader’s First Name: *

6th Grader’s Last Name: *

School for 6th Grade – Please choose from a list below or type in the “Other School” box for a school name that is not listed.

Geneva CUSD 304 Schools:

St. Charles CUSD 303 Schools:

Batavia Public School District 101 Schools:

Kaneland CUSD 302 Schools:

Central CUSD 301 Schools:

Private Schools:

Other School:

Please type the full name of the school - Homeschooling is listed above as an option in each district.

Grade Level: *

I have a child who attended Compass, Trek, Star K-3, Chick Chat, or CORE in the past: *

Dietary & Medical Info to better serve your 6th grader: *

Vegetarian, Food Allergy, or Medical Condition (severity and how to handle it) - or type NONE.
*Please Note: Children with severe food allergies will need to bring their own snack and lunch on the day of the event.

Information about your child:

We want your child to have the best possible experience at this event. Please note any information about your child that you think would be useful for the facilitators to know.

List Friends You Would Like to Be In Your Child's Group OR Type "Meet New People": *

Please invite the friends you list. Additional participants may be added to complete the group.

Additional Information

Participant Address: *

City, State and Zip: *

If living in unincorporated area, Township:

When TCFS seeks grants to help offset the costs of providing Emotional Wellness Programs such as Trek, TCFS is often asked to report on the numbers of participants per township.

To help us with grant applications and with future program planning, please answer:
Do you have one or more children age 5 years-old or younger?

Answer:

Telephone of Parent/Guardian to contact, if necessary, about the registration, but please note that email will be the primary method of communicating event updates.

Telephone: *

Please add trek@tricityfamilyservices.org to your email contact list to try to avoid email being misdirected to your Junk mailbox.

E-mail: *

Parent/Guardian e-mail to share event updates.

Emergency Contact: *

Relationship to Participant/s: *

Phone: *

Emergency Contact's Phone Number during the event.

Alternate Emergency Contact:

Relationship to Participant/s:

Phone:

Alternate Emergency Contact's Phone Number during the event

Contact me about volunteering for the event: *

Volunteers might help with set-up, clean-up, check-in, serving lunch, or other tasks to help the workshop run smoothly.

PERMISSION FORM FOR TREK FOR 6TH GRADERS AND LIABILITY WAIVER

I give my permission for my child/children to attend the Trek for 6th Graders event on 11/15/2025 (or on a rescheduled date if the Trek for 6th Graders workshop on 11/15/2025 must be cancelled and rescheduled as a result of inclement weather or other circumstances beyond TriCity Family Services' control) at Geneva Middle School South. Trek for 6th Graders uses a curriculum created by Navigate Adolescence. I hereby release and indemnify Navigate Adolescence, Inc., and its officers, TriCity Family Services (TCFS) and its officers, agents, employees, and volunteers, the Geneva Coalition for Youth and its officers and volunteers, Geneva Middle School South, Geneva CUSD 304, St. Charles CUSD 303, Batavia Public School District 101, Kaneland CUSD 302, Central CUSD 301, East Aurora School District 131, West Aurora School District 129, and the event sponsors and volunteers from any liability arising from any claims, damages, or injuries of any kind or nature whatsoever from my child/children's participation in this event. I grant permission for the administration of first aid to my child/children by the people in charge of the event as their judgment deems advisable and that I will be responsible for payment of any medical services rendered. I understand that I will be promptly notified in the event of any serious accident or illness. In the event I cannot be reached, I hereby give permission to the people in charge of the event, emergency personnel and physicians to secure proper treatment and to order injections, anesthesia, or surgery if deemed necessary for my child/children. I also recognize that my child will be withdrawn from the event if TriCity Family Services facilitators feel that my child poses a risk to the safety or well-being of or a significant distraction to the participants in the Trek for 6th Graders event.

I give consent to the use of my own or my child/children's photograph/image, voice, written, and or verbal statements, by Navigate Adolescence and TriCity Family Services in publications, videotaping, advertisements, brochures, websites, etc. I agree that Navigate Adolescence and TriCity Family Services may use my own or my child/children's photo/image without my permission for lawful purposes including the above. I further acknowledge that there is no agreement or promise on the part of Navigate Adolescence and TCFS to compensate my child/children or me in any way for the use of these photographs/images. I hereby release Navigate Adolescence and TCFS from any and every personal or proprietary claim, demand, right or cause of action of whatever kind or nature, either in law or equity arising from the use of these photographs/images. I have read and fully understand the terms of this release.

The information presented at Trek for 6th Graders is provided as a service to the community. The information shared is not intended to serve as, or substitute for professional counseling. All information shared will be kept in strict confidence by all TCFS and Navigate Adolescence personnel unless matters which indicate possible harm to or by a participant are revealed. All Trek for 6th Graders event staff and volunteers are mandated reporters. Confidentiality among the children participating in Trek for 6th Graders will be encouraged but cannot be guaranteed.

Permission and Liabilty Waiver: *

I have read and agree to the terms of the above “Permission Form for Trek for 6th Graders & Liability Waiver”.

If you chose not to agree, then you will not be able to use the online registration process for Trek for Sixth Graders. If you have questions, please call: Michelle Clark, LCPC, NCC, Director of Emotional Wellness Programs at TriCity Family Services (630)232-1070, ext. 304, or visit www.tricityfamilyservices.org for more information about Trek for Sixth Graders.

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone: *

E-mail: *

A receipt will be e-mailed to this address.

Once your transaction is complete, you will receive a receipt via email from Acceptiva - SAVE THE ACCEPTIVA RECEIPT AS PROOF OF REGISTRATION. If you do not receive an automated receipt from Acceptiva, contact Michelle Clark.

Questions? Call: Michelle Clark, Director of Emotional Wellness Programs at TriCity Family Services (630)232-1070, ext. 304. Or, email trek@tricityfamilyservices.org . You can also visit www.tricityfamilyservices.org for more information about the Trek for 6th Graders workshop.

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date:

Name on Account:

Routing Number:

Account Number: