FOCUS

FAMILY OUTREACH CENTER FOR UNDERSTANDING SPECIAL NEEDS

11901 Business Blvd, Suite 209

Eagle River, AK 99577

907-694-6002

2015/2016 AFTER SCHOOL PROGRAM REGISTRATION PACKET

To be completed by parent/guardian only - Please Print Legibly

Participant: ______Birth Date:______Age: _____ Gender: M / F

Home Address: ______City: ______Zip: ______

Mailing Address: ______City: ______Zip: ______

Email Address: ______

Parent or Guardian: ______

Home Phone: ______Work Phone: ______

Cell Phone #1: ______Cell Phone #2: ______

If you’re not currently receiving service from FOCUS, please include a copy of the plan of care (POC) with the registration packet, as well as the name of your care coordinator. ______

Taekwondo Program: Participants are responsible for a registration fee of $35 which is applied to membership for our Taekwondo program. Please make out a separate check to “FOCUS” for the $35 fee and enclose it with this registration form.

Emergency Contact: ______

Home Phone: ______Cell Phone:______Work Phone:______

School Participant Attends:______Contact Number:______

Teacher responsible for placing participant on bus:______

Name of individuals with permission to transport to and from the program:

______

______

There will be limited availability for transportation to and from the program by our staff. Please contact Shelby Carradine, Youth Programs Coordinator to arrange transportation.

The 2014/2015 After School Program will run from Wednesday, August 20, 2014 (the first day of school for the Anchorage School District) until Thursday, May 21, 2015 (the last day of school.) We will be open from 2-6 pm, participants may be picked up between 5 and 6 PM. We spend part of each afternoon out in the community and cannot guarantee we will be back at our building before 5 pm. The FOCUS After School Program will follow the Anchorage School District calendar.Extended programs may be offered on in service days and holidays, ASP will be closed with any ASD closures due to weather. On the ASD half days, our program will begin at 11 AM to accommodate the early school dismissals.

Our behavior policy is as follows: Any participant displaying excessive inappropriate or aggressive behavior will be asked to leave the program for the remainder of the day. If this occurs, please promptly pick up your participant. The participant may return the following day. If inappropriate or aggressive behavior continues, a conference between staff and the participant’s parent/guardian will be arranged.

Please indicate with a check in the box of which days of the week the participant will attend the After School Program:

Monday: Tuesday:Wednesday:Thursday:Friday:

______

If this information changes for any reason during the school year please notify Jamie Davis, Youth Programs Supervisor at (907) 694-6002 ect.7250.

INSURANCE/RELEASE of LIABILITY

I understand that this participant will be included in various activities with FOCUSAfter School Program. I agree that I will not hold FOCUS liable for injuries that occur as a result of participation in program activities. I assume all foregoing risks and accept personal responsibility for injuries, the damages following injury, permanent disability or death. I release, waive, discharge and covenant not to sue FOCUS, its affiliated employees, representative administrators, directors or other program participants.

I release and agree to hold harmless FOCUS from any and all liabilities to this participant’s involvement or participation in the FOCUS After School Program, even if arising from their negligence.

______

Parent/Guardian SignatureDate

FIELD TRIP and TRANSPORTATION PERMISSION FORM

I understand that FOCUS After School Program participants will be engaged in a number of off-site field trips. I give permission for this participant to go on field trips and activities. I understand that transportation to and from program activities will be provided by FOCUS employees. I give permission for FOCUS employees to transport this participant, demonstrating reasonable care and safety;to and from program activities in the Eagle River, Mat-Su Valley and Anchorage areas.

______

Parent/Guardian SignatureDate

VIDEO, SLIDE, PHOTO CONSENT

Yes I give FOCUS permission to photograph or video this participant and to use these pictures and/or video to promote our agency throughout the community. For example,photos may be used for applying and reporting use of grant funds, training and educating staff, or for informational purposes such as articles, news clips, and internet postings to included Focus website, Focus Facebook page, and blogs.

No, I do not give permission for FOCUS to photograph or video this participant.

______

Parent/Guardian SignatureDate

AUTHORIZATION for EMERGENCY MEDICAL TREATMENT

In case of a minor injury or illness, I give my permission for FOCUS employees to administer First Aid. I understand that personnel will alert me whenever minor First Aid care is given. In the event of a major injury or illness, I authorize FOCUS to call for emergency medical treatment or provide transportation to emergency services as needed. Parents or guardians will be contacted immediately. I further agree to bear all cost of emergency services provided in cases of injury or illness.

______

Parent/Guardian SignatureDate

Current Medications

Dose of Medication: ______

Administration: ______

Time of Day: ______

Reasons for medication: ______

Contact Information for Prescribing Doctor:

______

Is the participant known to have seizures?

Yes

No

Seizure medication: ______

Yes, I give FOCUS employees permission to administer the medications listed above to this participant.

______

Parent/Guardian SignatureDate

Please describe warning signs of emotional or physical outbursts.

______

Describe techniques you have found to control inappropriate behaviors.

______

Please describe any and all known fears that a participant experiences.

______

Please specify type and degree of assistance that may be required in each of the following areas:

Eating: ______

Dressing: ______

Grooming: ______

Toileting: ______

Protective Undergarments: ______

Please give us any other additional information you believe could aid us in providing a safe and fun After School Programexperience for this participant.

______

______

Parent/Guardian SignatureDate

1