Be Strong After School Club Student Application

Location *

Has your child ever participated in our Be Strong After School Club program? *

Child's First Name *

Child's Middle Name (Optional)

Child's Last Name *

Child's Date of Birth *

Child's Gender *

BSASC Public School County

Public School ID (NO STUDENT ID-PRIVATE SCHOOL)

Child's School Name *

Child's Current Grade *

Child Proficient in English *

Other Language(s) Spoken in the Home *

If Selected "Other" for Other Language(s) Spoken in the Home Please List:

Child's Home Address (Include Apt.) *

Child's City *

Child's T-Shirt Size (Please note shirts come in adult sizes) *

Child's Ethnicity *

If Selected "Other" for Child's Ethnicity Please List:

Child's Race *

If Selected "Other" for Child's Race Please List:

Is your Child presently engaged in or taking part in any sports-related activities? *

Does your Child Have Health Insurance: (ex. Private Insurance, KidCare, Medicaid) *

If NO, we may be able to help you find affordable coverage-call 211 or visit www.thechildrentrust.org Please note that The Children's Trust may Contact you via postal mail, email and/or text to ask about your satisfaction with these services, and to make you aware of other Trust-funded programs, initiatives and events you may be interested in.

Child's Insurance Information

If child has no current insurance coverage, please type N/A below for not applicable.

Child's Insurance Carrier *

Child's Doctor's Name *

Child's Doctor's Phone *

Parent/Guardian Information

Please be aware that you may be contacted by the Children's Trust to ask about your satisfaction with these services

Primary Caregvier's First Name

Primary Caregiver's Last Name

Relation To Child *

Cellular # *

Home or Work# *

Email *

Secondary Caregiver (Full Name) *

Seconday Caregivers's Relation To Child

Secondary Cellular# *

Secondary Home or Work# *

Secondary Email

Does your child live with a legal guardian other than mother or father? *

Family Status *

If Selected "Other" for Family Status Please List:

Is your child part of the dependency system? (Ex. DCF, Our Kids, Full Case MGT. Agencies, Family Courts) *

Is your child a part of the delinquency system? (Ex. Dept. of Juvenile Justice, Civil Citation Programs, etc.) *

Child's Medical Information

We want to get to know your child better so we can provide the best possible experience in our programs. Please tell us more about your child. I give permission for this information to be submitted to the Trust for program quality/evaluation purposes.

1. What are the main ways your child communicates? (Mark all that apply) *

2. What, if any, help does your child receive at this time? (Mark all that apply) *

3. What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *

4. My child has an Individualized Education Plan (IEP) or 504 plan. (Please provide IEP or 504 plan documents to site staff) *

5. Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do? *

6. To support your child's successful participation in this program, in what areas might she/he need additional assistance? *

7. Please check if anything applies to your child. If nothing applies, choose N/A *

Food Allergies (Type "N/A" if none apply) *

Other Serious Allergies *

If Selected "Other" for Other Serious Allergies Please List

Chronic Health Conditions *

Physical Limitations Which Affect: Learning, Physical Fitness Activities, and Social Engagement *

EXCEPT AS NOTED ABOVE my child is in good health, has no medical, food, other chronic allergies or serious health conditions. My child does not take medication routinely and his/her immunizations are current. If there is anything else you consider we need to know about, to better understand and provide the necessary help your child deserves, please speak to your Site Supervisor. All information is kept confidential and stored in locked cabinets.

Child's Emergency Information

I understand that every effort will be made to reach me for instructions if my child should become ill or injured while on the site or on a field trip. If in the judgment of the staff or a medical professional, delay in reaching me might jeopardize my child's well-being, I hereby authorize the staff or medical professional to secure whatever medical treatment is deemed necessary, including the administration of anesthetics and surgery.

IN THE EVENT THAT NO ONE CAN BE CONTACTED, I GIVE PERMISSION FOR MY SON/DAUGHTER TO RECEIVE EMERGENCY MEDICAL TREATMENT.

If you would like for us to follow a different emergency/medical procedure, please write it/explain below *

Emergency / Alternative Pick Up Contact Information:

Other phone numbers where I can be reached during the day *

If I cannot be reached, please contact my designated alternate(s) named below:

1. Full Name *

Relationship to Child *

Cellular or Work Number *

Authorized To Pick-Up? *

2. Full Name *

Relationship to Child *

Cellular or Work Number *

Authorized To Pick-Up? *

3. Full Name *

Relationship to Child *

Cellular or Work Number *

Authorized To Pick-Up? *

Please note: Any Family or friends authorized to pick up your child, must have a valid picture ID for verification purposes. A copy of ID will be taken by site staff and placed in student's file for future confirmation. In the event that I, the legal guardian am not able to pick up my child on time, I will contact the site supervisor and will authorize her/him to release my child to the person(s) listed above.

Policy Information/Consent

Non-Discrimination Policy: Children without documented legal status, or whose parents are without documented legal status will not be discriminated against for selection in these programs. As with the Miami-Dade County Public School system, all children are welcome. Children with severe physical, emotional, or behavioral disabilities may find after-school programs specially designed to meet their needs through other programs, every effort will be made to find the most suitable placement for each child.

Parental Consent: By signing this application, I agree and certify to the following:

1. I acknowledge that the application information and medical information I have provided above is true and complete to the best of my knowledge and ability.

2. Virtual Programming Consent

As the legal guardian, (please mark appropriate) I DO authorize of I DO NOT authorize Be Strong Int'l staff, to provide virtual programming to my child. *

Phone number or email that the virtual program link can be sent to is: (in regards to the above statement) *

As a part of the virtual programming, I DO authorize or I DO NOT authorize Be Strong Int'l staff to mail my related supplies and assessments. *

3. As the legal guardian of the child stated above, I DO authorize and give consent or I DO NOT authorize nor give consent to Be Strong Int'l staff, The Children's Trust, other BSI funders, or service providers to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotape recordings (hereinafter Recordings) of me, my children, or my wards for educational, research, documentary, and public relations purposes. Any such Recordings may reveal my identity through the image itself without any compensation to me, my children, or my wards. With regard to the use of any Recordings taken of me, my children of my wards, I hereby waive any and all present and future claims I may have against BE STRONG or TCT, and their staff, funders, service providers, employees, agents, affiliates and Board members.

Photography Consent *

4. I understand that participation by my children in the Program sponsored by Be Strong Int'l, The Children's Trust and its partners involves physical education, meals, and off-site field trips. As these activities may carry some degree of risk to my child's physical and emotional health, I hereby release, hold harmless and waive all claims associated with out-of-school/summer camp program activities from Be Strong, and the program site and all employees, officers, directors, agents, and volunteers associated with the out-of-school/camp program.

5. I understand that no medication/medial equipment will be administered by the afterschool personnel to my child without the "Authorization for Prescription and Non-Prescription Medication/Medial Equipment Form" signed by me as the parent/legal guardian. I also agree to provide instructions on how and when the medicine/medical equipment should be administered if my child were to need assistance with it. (Please , refer to the Family Handbook for more details).

6. As my child attends an Out-of-school (After-school) program primarily funded by The Children's Trust, acknowledge and understand that my child must adhere to all behavioral and policy driven rules and regulations the program sites require. Failure to abide by these rules, may lead to suspension and/ or removal of the program. I also acknowledge receipt of a written Family Handbook for this current program year, which details policies and procedures regarding my child and the program.

7. My child will be arriving and leaving from the site in the following manner (answer for both A and B below)

A. Leaving the site on regular days (non-field trip) *

B. Arriving/Leaving the site on field trip days *

I do not give permission, under any circumstances, for my child to leave the program site with: (include relationship to child) * If possible, bring a picture to keep on file. My child is allowed to go home with mother, father or legal guardian unless we have court documents stating otherwise due to custody battle or abuse. *

8. I agree to make every effort to ensure that my child participates in the program daily unless he/she is too ill to attend. I also agree that he/she can sign themselves out at the end of the program.

9. I understand that I am responsible to pick up my child at the end of the program day, arrange for an authorized person to pick up my child, or approve for my child to walk home. Only those persons previously authorized in writing, may leave the premises with my child. I am aware that my child may be withdrawn from the program for consistent failure to pick-up my child at the end of the day. Each day programming ends at 4:20 PM at Lake Stevens Middle School. I acknowledge that the program's Late Pick-up Policy/No Show Procedure is further detailed in the BSASC Family Handbook.

10. I understand that I need to call the program's Site Supervisor if my child is not attending on a particular day so that that Supervisor is aware that my child will not be showing up on that day.

11. I understand that I am releasing Lake Stevens Middle and Be Strong Intl. Youth Enrichment Program of any liability once my child has signed out from the program or leaves the program without signing out.

12. BSASC will connect with teachers to provide academic assistance. Children with disabilities will receive specialized assistance as available.

I give my permission for the information in this application to be submitted to The Children's Trust for program quality and evaluation purposes provides funding for the program. If you are interested in other services funded by The Children's Trust please call 211 or visit www.thechildrenstrust.org.

I am signing that I have reviewed and agreed to all terms and conditions described in this application, all the program standards, Policies and Procedures and Parent Handbook: (Include First and Last Name) * I also acknowledge that I may be requested to provide a hand written signature or initial to this application prior to or upon the start of the program.

Parent/Legal Guardian Signature *

Clear

Today's Date *

Be Strong International, Inc.