Enrollment Application 2014-2015
STUDENT INFORMATIONName: ______Date of Birth: _____/_____/____
(last) (first)
Address: ______Home Phone:______
Gender: □ Male □ Female Grade
in Sept: ______
Race/Ethnicity: Please choose ONLY one.
□ White □ Black □ Asian □ Hispanic □ Other: ______/ Special Ed: □ Yes □ No
Lunch: Free □ Yes □ No
Reduced Lunch:□ Yes □ No
Primary Language spoken at home:______Limited English proficiency: □ yes □ no
Please circle the days your child will be attending: M T W TH F (must attend a minimum of 3)
PARENT / GUARDIAN INFORMATION
Mother / Guardian Name: ______Date of Birth: _____/_____/_____
Race/Ethnicity:□ White □ Black □ Asian □ Hispanic □ Other: ______
Address: ______/ City/Zip: ______
Home Phone: ______/ Cell No.: ______
Work No.: ______/ E-mail: ______
Father / Guardian Name: ______Date of Birth:_____/_____/_____
Race/Ethnicity: □ White □ Black □ Asian □ Hispanic □ Other: ______
Address: ______/ City/Zip: ______
Home Phone: ______/ Cell No.: ______
Work No.: ______/ E-mail: ______
TRANSPORTATION
How will your child be getting home? (Please Check One)
o Bus / o Pick-up / o Walking
If child is being picked up, please provide names of authorized persons.
Name: ______/ Phone #: ______/ Relationship: ______
Name: ______/ Phone #: ______/ Relationship: ______
Name: ______/ Phone #: ______/ Relationship: ______
For your child’s safety, please call the 21st CCLC office at 732-787-2007 ext 2777 or the KAP cell phone at 732-778-5004 if your child will be absent from the program, even if your child is absent from school during the regular school day.
EMERGENCY / MEDICAL INFORMATIONDoes your child have any disabilities? ______If yes, please explain: ______
______
Does your child have any medical restrictions/allergies? ____ If yes, please explain: ______
______
Is your child currently taking any medication? ____ If yes, please explain: ______
______
Does your child have any academic or behavioral issues? ______If yes, please explain:______
______
Doctor’s Name: ______
Address: ______/ Phone #: ______
Child’s Insurance Company: ______
ID#: ______/ Group #: ______
EMERGENCY CONTACTS
Name: ______
Address: ______/ Phone #:
______/ Relationship:
______
Name: ______
Address: ______/ Phone #:
______/ Relationship:
______
Name: ______
Address: ______/ Phone #:
______/ Relationship:
______
In case of an emergency:
· The parent / guardian will be contacted immediately.
· The child’s physician will be contacted
· We will attempt to contact parent / guardian through one of the emergency contacts listed.
If the staff of the Keansburg 21st Century Community Learning Center can’t contact your child’s physician, staff will call for emergency first-aid assistance / transportation and/or have the child transported to an emergency hospital in the company of a staff member.
I state that I am the parent / guardian having legal custody of the child name in this document and attest that the information is correct. I authorize the above center project director or the director’s designee to obtain emergency treatment for my child.
______
Parent / Guardian Signature Date
I understand that my child must attend a minimum of three afternoons per week, as per grant guidelines.
I also understand that students participating in the program will be held to Keansburg School District’s standards for behavior. Repeated disruptions or disrespect for others and/or for their property may result in suspension or removal from the program.
______
Parent/Guardian Signature Date
NAME OF PARTICIPANT:______
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: My child is permitted to participate in: (Please check all activities that apply)
o Clubs / o Sports and Recreational Gameso Academics / o Community Service
o May walk to KHS and PMRS for any KAP activities
(hereinafter called “Activity”), I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Keansburg School District, its board of education, administrators, employees, and agents for liability arising from any and all claims including the negligence of Keansburg School District, its board of education, administrators, employees and agents, resulting in personal injuries, accidents or illnesses (including death), and property loss arising from participation in the Activity.
______/ ______Signature and date of parent/guardian / Signature and date of student
Assumption of Risks: Participation in the activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the activity. I hereby assert that my/my child’s participation is voluntary and that I knowingly assume all such risks.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Keansburg School District HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my/my child’s involvement in the activity.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of New Jersey and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend this agreement, by my signature, to be a complete and unconditional release of all liability to the greatest extent allowed by law.
______
Signature of Parent Date Signature of Participant Date
I give permission to the 21st CCLC program to take videos/pictures that may include my child and might be used in publications (e.g. newspaper, newsletters, 21st CCLC website).
______
Signature of Parent Date
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Created 11/04