Reef House Teen Center Registration Form

Transcription

1 Reef House Teen Center Registration Form Entrance Date: Withdrawal Date: Child's Name: Sex: Age: Date of Birth: Home Address: Home Phone Number: Father s Name/Home Address/Telephone Number, (If different from child s) Place of Employment/Address of Employment/Telephone Number/Business Number Mother s Name/Home Address/Telephone Number, (If different from child s) Place of Employment/Address of Employment/Business Number Child s Living Arrangements: [ ] Both Parents [ ] Mother [ ] Father [ ] Other Child s Legal Guardian: [ ] Both Parents [ ] Mother [ ] Father [ ] Other Number of other children living in the home: The child may be released to the person(s) signing his agreement or to the following: Name Address Phone Number Relationship Maternal/Paternal Maternal/Paternal Person(s) to contact in the case of an emergency when parents cannot be reached: Name Phone Number Relationship Maternal/Paternal

2 Name of School: Grade: Teacher: Child s Primary Health Source: Phone Number: Does the child have any special needs, physical problems, mental or behavioral disorders, mental retardation or developmental disabilities which could limit the child s participation in the center s program and activities? Yes No If so, please specify: List any allergies, illnesses and/or other problems the staff should be made aware of (e.g. Insects, medications, food, plants, etc.)? Are any special procedures required in caring for your child? Yes No If so, please specify and give schedules/dates: Permission for Participation I, grant permission for the above named student to participate in the Reef House Teen Center After-School Program. (Signature of Parent or Guardian) (Date)

3 HOLD HARMLESS AND LIABILITY RELEASE AND WAIVER AGREEMENT I,, the parent/legal guardian of the child named below, have voluntarily submitted my child for registration as a participant in Future Foundation, Inc. s Reef House After-school Program ("Future Foundation") and all programs associated therein. I certify that I am fully aware of and understand the inherent dangers in participating in any of Future Foundation s programs. I understand and agree that Future Foundation staff or any other participants will not be responsible for my child s safety nor will any of these parties or individuals serve as a guardian of my child s safety. In consideration for the services and programming provided to me and my child by Future Foundation, I, and each of my respective heirs, executors and administrators, hereby indemnify and hold harmless, and fully and forever release and discharge, Future Foundation and all of its officers, directors, employees, agents, volunteers and affiliates (collectively referred to herein as Affiliates ), acting officially or otherwise, from and against any and all claims, demands, actions, causes of action, liability, costs, damages or injury, whether known or unknown, foreseen or unforeseen, suspected or unsuspected, which in any way arise from the services or programming provided by Future Foundation and/or its Affiliate(s) to my child. I hereby agree to accept all responsibility for the risks, conditions and hazards that may occur, whether or not they are now known. I further state that I am of lawful age and legally competent to sign this agreement and that my signing this agreement is my own free act. I also understand and agree that the terms herein are contractual, and they are not a mere recital or simply for informational purposes. I have read, understood and fully informed myself of the contents of this agreement. I assume responsibility for my child s physical condition and capability to perform under the program. Child s Printed Name: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

4 EMERGENCY MEDICAL AUTHORIZATION FORM Child s Name: Date of Birth: Mother s Name: Home Phone: Work Phone: Father s Name: Home Phone: Work Phone: In an emergency and parents cannot be reached, contact: 1. Name & Relationship: Phone: Maternal/Paternal 2. Name & Relationship: Phone: Maternal/Paternal Child s Primary Source of Health Care is: Physician/Clinic Name: Phone Number: Child s Allergies: Current prescribed medication: Known medical needs and conditions: Should suffer an injury or illness while in the care of Reef (Child s Name) House Learning Center and if the center is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for my child as may be necessary. I (we) shall assume full responsibility for payment of all medical expenses incurred during the treatment. Reef House Teen Center agrees to keep me informed of any incidents requiring professional medical attention involving my child. I hereby release and forever discharge Future Foundation, Inc., Reef House Teen Center, and all of its officers, directors, employees, agents, volunteers and affiliates (the Future Foundation Parties ) from any claim whatsoever which arises or may arise on account of any first-aid treatment or other medical services provided by the Future Foundation Parties to my child. (Signature of Parent or Guardian) (Date)

5 AUTHORIZATION TO ADMINISTER BASIC FIRST AID/MEDICATION Child s Name: Date of Birth: Please check the appropriate box authorizing basic first aid treatment and/or the administration of approved medications. NOTE: An unchecked box means that aid or medication will not be administered. I authorize administration of basic first aid, including but not limited to: splinter removal, antibiotic cream, band-aids and ice. Unauthorized Treatments: I authorize administration of the medications listed below: Date(s) to administer: From To: Medicine Name(s) Time(s) to administer Amount NOTE: Please be advised that Reef House staff is not responsible for any reactions to the medications or missed dosages. Every medication must come in its prescribed container, with the child s name printed on it. By signing below, you acknowledge and agree to the above listed conditions. (Signature of Parent or Guardian) (Date)

6 TRANSPORTATION AGREEMENT I hereby give permission for my child to be transported by Future Foundation, Inc. or Reef House After-school Program (collectively, Future Foundation ), from school, to home, and on any field trip/outing that I sign him/her up for during the school year and/or summer program. I acknowledge and agree that once a field trip has been scheduled, a separate permission slip form will be sent home with my child to be signed by me and returned. In consideration for the transportation provided by Future Foundation, I,, the parent/legal guardian of the child named below, and each of my respective heirs, executors and administrators, hereby indemnify and hold harmless, and fully and forever release and discharge, Future Foundation and all of its officers, directors, employees, agents and volunteers (collectively, Affiliates ), acting officially or otherwise, from and against any and all claims, demands, actions, causes of action, liability, costs, damages or injury, whether known or unknown, foreseen or unforeseen, suspected or unsuspected, which in any way arise from the transportation service provided to my child by Future Foundation or any other Affiliate(s). I hereby agree to accept all responsibility for the risks, conditions and hazards that may occur, whether or not they are now known. I acknowledge and agree that this form must be completed and returned to Future Foundation before the child is allowed to travel with Future Foundation or any Affiliates from school, to home, or on any field trips/outings during the school year and/or summer program. Child s Name: Date of Birth: Parent/Guardian Name: Home Address: Emergency Contact Number: I authorize permission to transport my child during these times: NOTE: An unchecked box means permission is not granted during that specific timeframe, and the participant will not be allowed to travel, even when space is available. I authorize my child to be transported during both the school year and summer program. I authorize my child to be transported during the school year program ONLY. I authorize my child to be transported during the summer program ONLY. I hereby agree to the terms and conditions above and give permission for my child to be transported by Future Foundation or its Affiliates from school, to home, and on any field trips/outings that I sign him/her up for during the school year and/or summer program. (Signature of Parent or Guardian) (Date)

7 PARENT RELEASE FORM FOR MEDIA RECORDING I, the undersigned parent/legal guardian of the child named below, do hereby grant or deny permission to Future Foundation, Inc. to use the image of my child,, as marked by my selection(s) below. Such use may include the display, distribution, publication, transmission or use of photographs, images and/or video taken of my child for use in materials that may include, without limitation, printed materials (such as brochures and newsletters), videos and digital images (such as the Future Foundation website). I acknowledge that Future Foundation, Inc. and its successors and assigns own all right, title and interest in and to such films or photographs, and I hereby assign to Future Foundation, Inc. and its successors and assigns any and all right, title and interest therein and thereto.! I deny permission to use my child s image at all.! I grant permission to use my child s image in the following ways (mark all that apply):! Limited usage: I consent to my child s image being used within Future Foundation setting only (not in the larger community).! Limited usage: I consent to my child s image being used for educational materials only (not marketing), which could be either within Future Foundation or in the larger community (e.g., videos in parent education classes).! Limited usage: I consent my child s image being used on printed materials only (no digital or video use).! Unrestricted usage: I consent and give unrestricted permission for my child s image to be used in print, video and digital media by Future Foundation, Inc. I agree that these images may be used by Future Foundation, Inc. for a variety of purposes and that these images may be used without further notifying me. I acknowledge and agree that my child s last name will not be used in conjunction with any video or digital images. Child s Name: Date of Birth: (Signature of Parent or Guardian) (Date)

8 Reef House Computer, Internet, and Usage Rules Reef House Teen Center is pleased to offer participants access to a computer network for electronic mail and the Internet. To gain access to and the Internet, all Reef House participants must obtain parental permission verified by signatures on the Technology User Agreement & Parent Permission Form. Should a parent prefer that a student not have and Internet access, use of computers is still possible for more traditional purposes such as word processing. Reef House Participants Reef House participants are responsible for appropriate behavior on the computer network just as they are in any other client facilities. Communications on the network are often public in nature. Reef House s rules for behavior and communications apply. It is expected that users will comply with Reef House standards and the specific rules set forth below. The use of the network is a privilege, not a right, and may be revoked if abused. Reef House participants are advised never to access, keep, or send anything that they would not want their parents or staff to see. What are the rules? Privacy Network storage areas may be treated like school lockers. The Technology Instructor may review communications to maintain system integrity and will ensure that Reef House participants are using the system responsibly. Storage Capacity Users are expected to remain within allocated disk space and delete or other material that takes up excessive storage space. Illegal Copying Reef House participants should never download or install commercial software, shareware, or freeware onto network drives or disks, unless they have written permission from the Technology Instructor. Reef House participants should neither copy others work nor intrude their files. Inappropriate Materials of Language Profane, abusive, or impolite language should not be used to communicate nor should materials be accessed which are not in line with the rules of Reef House disciplinary policy. A good rule to follow is never to view, send, or access materials that you would not want Reef House staff or your parents to see. Should participants encounter such material by accident, they should report it to the Technology Instructor or Program Director immediately. Guidelines These are guidelines to follow to prevent the loss of network privileges at Reef House Teen Center. 1. Do not use a computer to harm other people or their work. 2. Do not damage the computer or network in any way. 3. Do not interfere with the operation of the network by installing illegal software, shareware, or freeware. 4. Do not violate copyright laws. 5. Do not view, send, or display offensive messages or pictures. 6. Do not waste limited resources such as disk space or printing capacity. 7. Notify any adult immediately if, by accident, you encounter materials that violate the Rules of Appropriate Use. 8. BE PREPARED to be held accountable for your actions and for the loss of privileges if the Rules of Appropriate Use are violated.

9 TECHNOLOGY USER AGREEMENT & PARENT PERMISSION FORM Please fill out all three (3) sections in this document. Any questions should be directed to the Program Director for clarification. As a parent/guardian of a participant in the Reef House After-school Program, I have read and understand the attached Reef House Computer, Internet, and Usage Rules regarding the appropriate use of computers at Reef House After-school Program, and I understand that this User Agreement will be kept on file at Reef House. Section A My child can use and the Internet while at Reef House as outlined in the Rules of Appropriate Use. My child can use the Internet only as outlined in the Rules of Appropriate Use. My child may not use or the Internet while at Reef House. Section B I understand that, from time to time, Reef House may wish to publish examples of participants projects, photographs of participants, and other work on an Internet-accessible World Wide Web server. My child s work and photographs can be published on the Internet. I prefer that my child s work and photographs not be published on the Internet. Section C As a user of Reef House After-school Program s network, my child and I agree to comply with the above stated rules and use the network in a constructive and safe manner. In addition, I understand that all precautions will be taken to ensure my child is protected from inadvertently connecting to an inappropriate site. In the event that an incident does occur, my child will report the incident immediately to the Program Director. Child s Printed Name: Child s Signature: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

10 INTERNET SAFETY ACKNOWLEDGEMENT FORM 1. I will not give out personal information such as my address, telephone number, parents work address/telephone number, or the name and location of my school. 2. I will tell the Tech Center Instructor right away if I come across any information that makes me feel uncomfortable or is inappropriate 3. I will never agree to meet in person or get together with someone I meet online. 4. I will never send a person my picture or any other personal information. 5. I will not respond to any messages that are mean or in any way make me feel uncomfortable. It is not my fault if I receive a message like that. If I do receive such a message, then I will tell the Tech Center Instructor right away so that they can contact the service provider. 6. I will not give out my Internet password to anyone (even my best friends) other than my parents. 7. I will be a good online citizen and not do anything that hurts other people or is against the law. Child s Printed Name: Child s Signature: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

11 Reef House Teen Center Education Partnership Authorization Form By signing this form, you are authorizing Reef House Teen Center to monitor your child s academic progress to better support his or her education needs. Upon approval, we will visit your child s school and talk with school Teachers and administrators regarding any academic problems or disciplinary issues and obtain school documents such as Transcripts, CRCT Test Scores, Immunization and Disciplinary records, and IEP if Applicable for the student listed below. All school visits will begin in August and continue throughout the end of the school year. Please print your name, your child s name, school name, teacher s name, and grade level in the appropriate space. I,, hereby authorize the Reef House Teen Center (Name of Parent/Guardian) to meet with my child s school administrators (i.e. teachers, counselors, etc.) of Middle School in an effort to enhance and (School Name) improve the academic performance of my child,, (Child s Full Name). I furthermore authorize the release of (Social Security Number) Fulton County Schools' academic and discipline records in order for the Reef House Learning Center to effectively assist my child with after school tutoring, homework, and enrichment activities. (Signature of Parent/Guardian) (Homeroom Teacher s Name) (Date) (Child s Grade Level)

12 ACKNOWLEDGEMENT OF RECEIPT OF PARENT HANDBOOK I acknowledge that I have received a copy of Future Foundation, Inc.'s Reef House Parent Handbook ("Handbook") on the date listed below, I have had an opportunity to read the handbook, and I accept its terms. I also understand that it is my responsibility to comply with the policies contained in the Handbook. I further acknowledge that the information, policies, and benefits described in the Handbook herein are subject to change at any time, and I understand that I remain responsible for compliance with any revisions made to the Handbook. Child s Printed Name: Parent/Legal Guardian Printed Name: Parent/Legal Guardian Signature: Date:

13 st Century Community Learning Centers Reef House Teen After-school Program Parent Agreement Dear Parent(s), Your child has been accepted in Reef House After-school Program s 21st Century Community Learning Center (CCLC) Program for the school year. The following guidelines for the program will be in effect for the entire year. Please read this agreement and acknowledge acceptance of these terms with your signature. Regarding attendance, late fees, and transportation, I understand that: The program s operating hours are 3:00 p.m. until 8:00 p.m. at Reef House Learning Center; and 4:00 p.m. until 8:00 p.m. at Reef House Teen Center each day school is in session. I am responsible for picking my child up from the program if transportation is not provided. If my child is not picked up by the program s ending time, I am responsible for paying $1.00 a minute after 8:00, which must be paid at pick-up. If my child is not picked up by 8:30 p.m.(learning center or teen center), and I have not notified Reef House staff of an emergency, the program staff will notify legal authorities and custody of my child will be turned over to them. Only five (5) unexcused absences per semester are allowed in the program. If my child is not in attendance more than 5 days and proper documentation has not been provided, he/she will be dismissed from the program. Regarding discipline, I understand that: My child may stay in the program if acceptable behavior is exhibited. Discipline problems will not be tolerated. If my child is disruptive, disrespectful to authority, abusive or threatening to other students in any way, he/she may be dismissed temporarily or permanently from the program. Severe violations may necessitate dismissal on a first offense. Regarding serious emergencies or illness, I understand that: The program will attempt to contact me or an authorized person listed on my child s registration form. If the Reef House staff is unable to reach me or my designee, I hereby authorize Reef House staff to take whatever action is reasonable to provide the necessary help for my child, including contacting emergency medical services or transporting my child to a medical facility. Regarding services, I understand that: Program activities are designed for students who are able to participate independently in age-appropriate activities within a 1:15 teacher/student ratio. Failure to disclose any information affecting your child s participation in group activities may result in his/her dismissal from Reef House. Regarding homework, I understand that: The program provides designated times for enrichment activities and homework help/tutorial. During homework time, staff is available for assistance. Though reasonable efforts will be made, staff is not responsible for ensuring that all homework is complete and correct. Regarding parental involvement, I understand that: I am required as parent/guardian to volunteer ten (10) service hours during the program year. I am required as parent/guardian to attend at least five (5) parent workshops during the program year. I am to support the program by attending special functions and activities, at least three (3) family fun nights during the program year. I have read, understand and agree to all policies and procedures as indicated on this agreement form. Child s Printed Name Parent/Guardian Signature Date