DC SCORES Registration Checklist

DC SCORES STUDENT REGISTRATION PACKET Dear Families, Welcome to DC SCORES! Enclosed you will find the materials necessary to enroll your child in DC SCORES for the 2013 2014 school year. Please carefully review all the enclosed materials. Complete and return all forms including the checklist below to your child s DC SCORES coach. This packet must be turned in before your student may participate in DC SCORES. What is DC SCORES? DC SCORES is an after school program for over 1500 students at 47 DC public and public charter elementary and middle schools. Our core values of teamwork, leadership, and commitment are carried out daily in a program model where students participate in soccer, poetry, and service learning. What is the weekly schedule? Monday Friday after school Students must attend both soccer and writing sessions each week What dates should I remember? The spring season begins March 10th and ends May 31st Weekly games begin April 3rd and 4th; see the schedule at www.dcscores.org (resource section) Jamboree! May 31st (all students) What if I have more questions? See the coaches at your student s school Call DC SCORES at (202) 295 7760 Check out our website at www.dcscores.org (resource section) Parent/Guardian Initials DC SCORES Registration Checklist FERPA form (pg.2) DC SCORES registration form (pg. 3) UPO Form with signature (pg.5) Parent/Guardian Signature Date

Application for the DCPS Afterschool Program Student Enrollment Form Part A Office of Out-of-School Time 1200 First Street, NE 8 th Floor Washington, DC 20002 202-442-5002 OutofSchoolTime@dc.gov Dear Parents/Guardians, In an effort to serve your child better in the afterschool program at his/her school, and to ensure that the program meets your child s academic needs, DCPS works with organizations that specialize in providing afterschool programs (Afterschool Providers). In order to more effectively tailor the afterschool program to your child s needs, further cultivate his/her strengths, and identify and develop areas where he/she is in need of improvement, DCPS would like to share certain student records related to your child with his/her school s Afterschool Provider(s). Under the Family Educational Rights and Privacy Act (FERPA), DCPS must first obtain your consent before sharing education records with the Afterschool Provider(s) at your child s school. Please indicate below whether you consent to give the Afterschool Provider(s) at your child s school access to your child s demographic data, test scores, quarterly grades and, if applicable, Individualized Education Program materials. If you choose to consent to DCPS sharing of this information about your child with the Afterschool Provider(s), you may request that DCPS provide you with a copy of the records disclosed. All staff members of the Afterschool Provider(s) with a right to access your child s education records have signed confidentiality agreements regarding the privacy of your child s education records. I consent to DCPS sharing of my child s demographic data, test results, quarterly grades and, if applicable, Individualized Education Program with the Afterschool Provider(s) at my child s school for purposes of academic enrichment. I do not consent to DCPS sharing of my child s demographic data, test results, quarterly grades and, if applicable, Individualized Education Program with the Afterschool Provider(s) at my child s school. Signature of Parent/Guardian Printed Parent/Guardian s Name Date Printed Child s Name Your Child s School

DC SCORES STUDENT REGISTRATION FORM PERMISSION WAIVER *Please be sure all parts of this form are complete to prevent any delays in processing your child s registration* As the parent or legal guardian of the minor child listed on the following page, I give permission for him/her to participate in the DC SCORES (hereinafter referred to as SCORES ) program at the school listed on the following page for the 2013-2014 school year. I understand that this permission slip includes my permission for my child to participate in all SCORES activities, including soccer practices, writing workshops and home and away games as well as all special events where transportation is hired and provided by SCORES, including but not restricted to: Fall Frenzy, Poetry Slam!, Shout!, and Jamboree!. I understand that SCORES assumes no responsibility for seeing to it that the minor reports to activities at the SCORES sponsored program, and I, on my own behalf and on behalf of this minor, waive all claims for any liability arising or actions occurring before the minor has reported to SCORES. I give permission to SCORES to collect and record data, including Body Mass Index (BMI) weight and height and waist/neck circumference, about my child with the understanding that all information obtained will remain private, and that any responses publicly reported will be grouped together with other participants of this program and that my child will not be individually linked to his/her response. Only the staff approved by DC SCORES will be able to view his/her responses. I authorize the release of data and information collected by my child s current or former school(s), including but not limited to grades, attendance, test information and other performance information, to verify information and utilize information for group reporting with an understanding that only staff approved by DC SCORES will have access to the information. RELEASE I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of SCORES and its affiliated organizations and sponsors. My child has received a physical examination and has been found physically capable of participating in the Program. Recognizing the possibility of physical injury associated with soccer and in consideration for SCORES accepting the registrant for its soccer programs and activities (the Programs ), I assume all risks and hazards incidental to athletic participation and hereby release, discharge and/or otherwise indemnify SCORES, its officers, directors, coaches, sponsors, volunteers, and agents, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. CONSENT FOR MEDICAL TREATMENT OF MINOR In the event of a medical necessity or emergency, I hereby authorize the adult representative of SCORES to make any necessary arrangements for the proper medical or surgical care of the above named child, and to give the required consents in connection therewith. I further authorize any medical, dental and/or emergency personnel selected by such adult representative to secure and provide necessary and proper medical treatment for the care of my child. I also give consent for my child to be transported by ambulance to an emergency center for treatment. I understand that I will be notified as soon as possible in the event that an emergency arises requiring medical assistance and I assume all financial responsibility for any medical treatment (including transportation) for my child. MEDIA RELEASE FORM I give my consent to the photographing, recording, and broadcast of my child s voice and likeness, performance and/or talents and any material as part of television, film, radio, still photograph, CATV program (referred to below as the "Programs"). I also consent to the use of my child s written work in SCORES, America SCORES, or other media publications. I acknowledge that SCORES is the sole owner of all rights in and to the Programs and the photographs, video footage, recording thereof, and written work, for all purposes, and that they have the right, among other things, to broadcast the Programs one or more times over any station or CATV system, or provide any other distribution of the Programs. I understand that my child and I shall receive no compensation for his/her appearance on and participation in the Programs. My child s name, likeness, or written work may be used in advertising and promotional material for the Program, but not as an endorsement of any product. As parent/guardian of registrant, I/we hereby assign to America SCORES all rights, including copyright, in any works created in whole or part by the registrant while participating in the Program. Turn Page

DC SCORES STUDENT REGISTRATION FORM Participant Child Information Child s Name: School Name: Nickname: Grade: DCPS Student ID #: Date of Birth: Gender: M F Child Email: Child Mobile Phone: Ethnicity: African American American Indian/Native Alaskan Asian Caucasian Haitian Hispanic/Latino Pacific Islander Other/Multi ethnic: Primary Language: Secondary Language: Has your child participated in DC SCORES before? If yes, where? Does your child receive free/reduced price lunch at school during the school year? Does your child have permission to walk, bicycle, or take public transportation home on their own? Please list any known allergies/medical conditions: Parent/Guardian Information Name: Address: Primary Language: City: State: Zip: Email Address: Phone: Relationship to Child: Parent Legal Guardian Foster Parent Grandparent Sibling/Other Relative Are you in the Military? Are you interested in being a volunteer for this program? If Yes, in what capacity? Coaching Events Game Day Field Monitor Other: I would like to receive email messages from DC SCORES at the address listed above I would like to receive text messages from DC SCORES at the number listed above Emergency Contact (Other than Parent/Guardian) Name: Relationship to Child: Phone : Does this person have permission to pick up your child? Primary Language: Email Address: Please list anyone that does not have permission to pick up your child: Insurance Information: Does your child have medical insurance? If yes, what is the insurance company? Chartered Health Plan Health Right Kaiser Permanente Blue Cross and Blue Shield Other: Policy Number: I/we, legal parent/guardian(s) of above named participant, agree to the terms listed on the previous page of this waiver and hereby certify that the statements in this application are correct and true. Parent/Legal Guardian Name (PLEASE PRINT) Parent/Legal Guardian Signature Date *INSURANCE FOR ALL DC SCORES PARTICIPANTS IS PROVIDED IN KIND FROM D.C. STODDERT SOCCER LEAGUE, INC.* Parents: Submit suggested $10 equipment and supply fee with this form to your coach

VERIFICATION OF CUSTOMER ELIGIBILITY FOR CSBG SERVICES FORM United Planning Organization Community Services Block Grant Program FY2014 Service Provider Name: DC SCORES Address: 1224 M St. NW, Suite 200, Washington, DC 20005 Student s Name: Student s School: Student's Address: City: Home Phone Number: Parent/Guardian Name: Total Number in Family Including Yourself: Student's Date of Birth: Zip Code: Alt. Phone Number: Family Income: SELECT ONE AND INDICATE AMOUNT: TRUTHFULLY INITIAL INITIALS Weekly Income: $ Semi Monthly Income: $ Bi Weekly Income: $ Monthly Income: $ (A family may be a single individual. For families of more than one individual, the definition of family means all persons living in the same household who are: (1) supported by the income of the spouse, parent(s) or guardian(s), and (2) related to the spouse, parent(s) or guardian(s) by blood, marriage, or adoption.) ONE OF THE THREE OPTIONS BELOW: (A) I have provided supporting documents to certify that I am eligible to receive CSBG services. You must provide a copy of at least one of the documents below with this form. Mark the checkbox of the documentation you have provided. Tax Return: Social Security Pension/Retirement: W2 or 1099 Supplemental Security Income TANF Income Statement Child Support: Military Family Allotments: Paystub: Alimony: Training Stipends: Other: Explain Other: INITIALS INITIALS (B) I have not provided supporting documents, but by initialing and signing g this document, and listing my income above, I certify that my income and my family income meets the criteria to qualify for CSBG services. (C) I have not provided supporting documents because my income and my family income is zero. Certification of Zero Income I hereby certify that neither I nor my family receive(s) income from any of the following sources: (a) Wages from employment (including commisson, tips, bonuses, fees, etc.); (b) Social Security payments, annuities, insurance policies, retirement funds, pension or death benefits; (c) Allowances such as alimony, child support, or money received from persons not living in my family; (d) Sales from self employment resources (Avon, Mary Kay, Shaklee, etc); (e) Income from operation of a business; (f) Rental income from real estate or property; (g) Interest or dividends from assets; (h) Unemployment or disability payments (i) Public assistance payments; or (j) Any other source not named above. Customer Information: You must initial on the appropriate line above to indicate that you have income and have provided documentation, have income and are unable to provide supporting documents to verify income eligibility but that your family income falls within the poverty guideline or that you have zero income. Additionally, you must sign the form. Note that the information provided on this form is solely for the purpose of determining whether you or your family are eligible for this program and will be kept confidential by UPO and/or its service providers. Customer/Parent Signature: Turn Page DO NOT WRITE BELOW THIS LINE. FOR STAFF ONLY. Name of Staff Person Verifying Eligibility: Customer's Total Annual Family Income: Is the Customer's Income Below 125% of the Applicable Poverty Level? Is the Customer a Resident of Washington, DC Presently? YES YES NO NO NOTE: CUSTOMERS FOR WHOM STAFF CANNOT ANSWER YES ON BOTH QUESTIONS ARE INELIGIBLE TO RECEIVE CSBG FUNDED SERVICES PROVIDED BY UPO OR SUBGRANTEES OF UPO.

FY 2014 SUPPORTING DOCUMENTATION CHECKLIST VERIFICATION OF CUSTOMER ELIGIBILITY FOR CSBG SERVICES United Planning Organization, Community Services Block Grant Program Provide a copy of one document from each section below. (Documents, including photographed copies, may be turned in to your child's DC SCORES Coach, emailed to upo@dcscores.org, or texted to 202.295.7760) PROOF OF IDENTITY (One of the following picture identification documents) Driver s License or Non Driver s Identification Card State Issued Picture Identification Card Temporary Assistance for Needy Families (TANF) Identification Card Passport Other: PROOF OF RESIDENCE (One of the following) Driver s License or Non Driver s Identification or Passport Utility Bill Phone Bill (Not Cell Phone Bill) Lease Agreement Mortgage statement/mortgage Deed Letter from Landlord or Home Owner Other: INCOME ELIGIBILITY SUPPORTING DOCUMENTATION (One of the following) Recent Pay Stub IRS Form W 2 IRS Form 1040 (Federal Tax Form) District of Columbia tax form D40 Temporary Assistance for Needy Families (TANF) Income Statement SSI Statement Unemployment Pay Stub Employer Income Verification Other: