GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR SCHOOL YEAR

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1 GLOBAL TECH ACADEMY INC. AFTERSCHOOL ENRICHMENT PROGRAM REGISTRATION PACKET FOR SCHOOL YEAR Welcome Child s Enrollment Form Parent Pick-Up Authorization Emergency Information, Waiver & Medical Authorization for Minors Child Immunization Record Media Release Form Contact Information Child s Name: Parent s Signature: School Name:

2 WELCOME Dear Families: We would like to take this opportunity to welcome you and your child to Global Tech Academy Inc. (GTA) Afterschool Enrichment program. Global Tech Academy Inc. is an exciting new technological computer enrichment program that's empowering a new generation of students who are serious about their future. At Global Tech Academy Inc., our mission is: to empower a new generation of students by integrating technology programs into everyday life to pave the way for the future and to be a company that implements genuine care, respect and courtesy for children, parents and each other. The goals of GTA afterschool program is to provide a quality program that is safe, fun and affordable. Our programs offer age appropriate activities under the supervision of competent, trustworthy, caring and qualified staff that understands and meets the needs of the children in our care. To meet the physical, intellectual, social, emotional and recreational needs of children, our program will: Offer fun, enriching, academically oriented and recreational activities that help promote confidence, self-esteem and responsibility. Provide children a safe and secure environment staffed by warm, friendly childcare professionals. Provide a relaxed atmosphere where children can socialize and make new friends. Provide a nutritional snack. Provide tutoring and homework assistance. At GTA, we believe that during the hours that the children are away from home they should be provided with a quality program of well supervised activities that stimulates new interests, encourages creativity and builds self confidence, while providing their parents with peace of mind. We are looking forward to providing you and your child with a quality afterschool enrichment program. Sincerely, Bernardo K. Baker CEO / President

3 GLOBAL TECH ACADEMY INC. CHILDREN S ENROLLMENT FORM Entrance Date Withdrawal Date Child s Name Sex Age Date of birth Home Address (Street) City State Zip Home Phone Number Father s Name Home Phone Number Father s Home Address (if different from child s) Street City State Zip Father s Place of Employment_ Work Phone Employer s Street Address City State Zip Mother s Name Home Phone Number Mother s Home Address (if different from child s) Street City State Zip Mother s Place of Employment_ Work Phone Employer s Street Address City State Zip Child s Living Arrangements: (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other Child s Legal Guardian(s): (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other

4 Persons to contact in the case of emergency when parent or guardian cannot be reached: Name Telephone Number Name Telephone Number Name Telephone Number Name of Public or Private School child attends, if any: Child s doctor or clinic name Doctor/clinic phone # My child has the following special needs _ The following special accommodation(s) may be required to most effectively meet my child s needs while at the center: _ My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns: _ EMERGENCY MEDICAL AUTHORIZATION Should (child s name) Date of birth_ suffer an injury or illness while in the care of (Facility name) and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services. Parent/Guardian: Signature Date:_ Facility Administrator/Person-In-Charge Signature Date:_

5 Parental Agreements with Child Care Facility The agrees to provide day care for (Name of Facility) on (Name of Child) (Days of Week) a.m. to p.m. from to. Month Month My child will participate in the following meal plan (circle applicable meals and snacks): Breakfast Morning Snack Lunch Afternoon Snack Evening Snack Dinner Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it. My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent (s), or facility personnel. I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child. The agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep. I authorize the child care facility to obtain emergency medical care for my child when I am not available. I have received a copy and agree to abide by the policies and procedures for. (Name of Facility) I understand that the center will advise me of my child s progress and issues relating to my child s care as well as any individual practices concerning my child s special needs. I also understand that my participation is encouraged in facility activities. Signed: Date: _ (Parent/Guardian) Signed: Date: _ (Facility Administrator/Person-In-Charge)

6 PARENT PICK-UP AUTHORIZATION Global Tech Academy Inc. wants to ensure your child s safe and enjoyable experience in our afterschool enrichment program. Please help us by agreeing to the following procedures: Ø I will sign out my child as I come to pick him/her up. Ø I will personally escort my child from the program area. Ø I will supply in writing the required information of those who are authorized to pick-up my child. Ø I understand that any changes to pick up list must be made in writing and I also understand that the receipt of any changes must be confirmed by Global Tech Academy Inc. staff in writing. Ø The adults I have listed below are AUTHORIZED to pick-up my child. Ø I understand that adults authorized to pick-up my child must present a valid photo ID (preferably a state driver s license or other form of government-issued identification). Ø I understand that if the name and address listed on the ID card does not EXACTLY MATCH that of the person picking up my child, my child may not be released. Ø I understand the Global Tech Academy Inc. staff will ONLY release a child to authorized adults listed below or adults listed as emergency contacts. Ø I understand that authorized adults must be 18 or older. *Name Address (Street-City-State-Zip) Telephone Number Relationship to child Relationship to Parent(s) or Guardian_ Other identifying information (if any) *Name Address (Street-City-State-Zip) Telephone Number Relationship to child Relationship to Parent(s) or Guardian_ Other identifying information (if any) *Name Address (Street-City-State-Zip) Telephone Number Relationship to child Relationship to Parent(s) or Guardian_ Other identifying information (if any) *Name Address (Street-City-State-Zip) Telephone Number Relationship to child Relationship to Parent(s) or Guardian_ Other identifying information (if any) Please list below any people who may not pick-up your child without additional written permission.

7 (Copies of any court order to support this should be kept with this form). Name: Relationship: Name: Relationship: ACKNOWLEDGEMENT OF POLICIES & GUIDELINES By signing below, I acknowledge that I have read the above information, and that I understand the policies and guidelines of the program and I agree to abide by them. Should I have any questions or concerns, I will contact the Program Director. I understand that the staff makes every effort to provide a quality program, but additionally it is important that participants and parents follow all rules, guidelines and procedures in order for the program to be a successful experience for all. Signature of Parent / Guardian: Date:

8 GLOBAL TECH ACADEMY INC. EMERGENCY INFORMATION, WAIVER, AND MEDICAL AUTHORIZATION Parent / Guardian Name:_Date Child s Information: Complete one form for each child. First Name: Last Name: Age: Birth Date: Male Female Are immunizations current? No Yes Has child been hospitalized or had operations, serious injuries, fractures, etc. in the past five years? No Yes Does he/she have any disability, special needs, chronic or recurring illness or conditions? No Yes Does he/she have any conditions requiring medical, treatment or special considerations while in this program? No Yes Are there any activities from which your child should be exempted for health reasons? Name current medications (prescribed or over the counter) and give instructions: List allergies and diet restrictions: If you answered YES to any of the questions above, please give details: Health Insurance Information: Physician s Name: at (hospital / clinic / office): Phone Number: Medical Insurance Carrier: Policy Number: Group Number: Initial Emergency Contact: Parent / Guardian to be contacted first: Phone: If the initial emergency contact cannot be reached, we will attempt to reach (Please include at least one relative and one available neighbor): Name: Relationship: Phone: Name: Relationship: Phone: Parent / Guardian Authorization: I certify that in advance of participation in Global Tech Academy Inc. programs, I have received any and all information which I deem necessary or important in making an informed choice regarding my child/ward s participation in such activity or program. I acknowledge the risks inherent in my child s participation in activities. In consideration of Global Tech Academy Inc. allowing my child/ward to participate in such activity or program, I hereby voluntarily agree to assume all risks of his/her participation in such activity or program. IN EXCHANGE FOR ALLOWING MY CHILD/WARD TO PARTICIPATE IN GLOBAL TECH ACADEMY INC. PROGRAMS AND SERVICES, I HEREBY AGREE TO RELEASE AND HOLD HARMLESS GLOBAL TECH ACADEMY INC. its employees, officers, directors and volunteers, from any loss, liability, claim of bodily injury or death or property damage, or costs which may arise due to my use of Global Tech Academy Inc. facilities and equipment and my participation in Global Tech Academy Inc. programs, including claims arising out of negligence of Global Tech Academy Inc. and its employees and volunteers. The use of all Global Tech Academy Inc. facilities shall be undertaken at the undersigned s own risk. This agreement shall be governed by the laws of Georgia. I give permission for my child/ward to participate on supervised field trips away from the site. The health information about my child that I have provided to Global Tech Academy Inc. (including

9 my child s Immunization records) is complete and correct so far as I know. My child/ward has permission to engage in all prescribed activities except as noted in his/her registration materials. Authorization of Treatment: I hereby give my permission to the medical personnel selected by the director to secure emergency medical treatment including but not limited to, first aid, DPR, admission to any hospital, test, surgery or general anesthesia, so long as care is provided by persons or facilities licensed in the state in which such treatment is rendered. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to secure and administer treatment, including hospitalization, for the child named above. The completed forms may be photocopied for field trips. I further acknowledge that any medical treatment ordered is my financial responsibility and not that of Global Tech Academy Inc. or any of its agents, volunteers or employees. Hospital Consent: Hospital has permission to treat my child (specify name of hospital): Acknowledgement of Policies & Guidelines By signing below, I acknowledge that I have read the above information, and that I understand the policies and guidelines of the program and I agree to abide by them. Should I have any questions or concerns, I will contact the Program Director. I understand that the staff makes every effort to provide a quality program, but additionally it is important that participants and parents follow all rules, guidelines and procedures in order for the program to be a successful experience for all. Signature of Parent / Guardian Signature: Date:

10 AUTHORIZATION FOR MEDICATION Child s Full Name: Name of Medication: Prescription Number: Time Medication is to be given: (Medication will not be given on an As Needed basis, specifics must be provided) Amount of Medication to be given: Dates to be given: (Not to exceed two weeks without a physician s statement) PARENT S SIGNATURE DATE FOR CENTER USE (Reminder: document the reasons why medications are not given as parent requested i.e., child absent, medication not sent, child sleeping etc ) DATE TIME GIVEN AMOUNT ANY ADVERSE REACTIONS ADMINISTERED BY If noticeable adverse reaction to medication, what action was taken? Describe: Attention to Person Requesting Medication Be Dispensed: Form must be completed in its entirety before the center can dispense any medication

11 Media Release I hereby consent to the use of my/my child s name, likeness and speech in any audio tape, video tape, film or photograph made in any Global Tech Academy Inc. Afterschool Enrichment Program activity for the business or publicity purposes of the Global Tech Academy Inc. Afterschool Enrichment Program and its partners. I understand that any participation offers no remuneration and that my/my child s name, likeness and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad. I expressly release the Global Tech Academy Inc. Afterschool Enrichment Program, its licensees, assignees, affiliates and successors from any privacy, defamation, or other claims have arising out of broadcast, exhibition, publication, or promotion of this program. - Please sign here if you do agree to the Media Release Parent / Legal Guardian Signature or Participant (if over 18) Date - Please sign here if you do not agree to the Media Release Parent/ Legal Guardian Signature or Participant (if over 18) Date

12 Contact Information: Global Tech Academy Inc Marketplace Blvd. Suite East Point, GA (b) (678) (c) Global Tech Boyd Elementary School 1891 Johnson Road NW Atlanta, GA Global Tech Burgess-Peterson Academy 480 Clifton Street SE Atlanta, GA Global Tech E.L. Connally Elementary School 1654 S. Alvarado Terrace SW Atlanta, GA Global Tech G.A. Towns Elementary School 760 Bolton Road NW Atlanta, GA Global Tech Humphries Elementary School 3029 Humphries Drive Atlanta, GA Global Tech Mt. Olive Elementary School 3353 Mount Olive Road East Point, GA Global Tech Toomer Elementary School 65 Rogers Street NE Atlanta, GA 30317

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