2020 CDF Freedom Schools of Licking County Scholar Enrollment Form

CDF Freedom Schools of Licking County - 2020 Scholar Enrollment
Enrollment is open for Freedom School! For 2020, the Rockin' Cool Freedom School will be operating in three locations: Northridge Primary School in Alexandria, Par Excellence Academy in Newark, and Christian Endeavor United Methodist Church in Newark.

Please complete all fields on this form. Write n/a for any item not applicable.

There is a registration fee of $25 per child ($10 if you meet the criteria). The form will guide you through the registration process. Registration fees can be paid in this form via Paypal. Registration is not considered completed until this form is completed and fees are paid. If your child has an IEP or 504 plan, you will need to submit a copy of that form to rcfreedomschool@gmail.com.

If you cannot pay via Paypal, you may send a check or cash to:

CDF Freedom Schools of Licking County

Neal Avenue United Methodist Church

12 Neal Avenue, Newark OH 43055

If you have any questions, please contact Laura Atherton, Project Director, at rcfreedomschool@gmail.com or 740-618-2300.
Location you are registering for:*

Alexandria Primary School (K-8)Par Excellence Academy (K-5)Christian Endeavor UMC (K-8)
Child Information

If requested information is not applicable or is unknown, please type N/A.
Child's full name*

First NameLast Name
Child's preferred name or nickname:
Child's t-shirt size*
Child's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth date:*

MonthDayYear
Gender*
Child's race/ethnicity*
Any languages your child speaks at home*
Ex. English, Spanish
Is your child an English Language Learner?*

YesNo
Type of school that your child attended this past school year:*
Grade completed this past school year:*
Please indicate the level at which your child is reading:*

Below grade levelAt grade levelAbove grade level
Child's school name:*
City of child's school:*
State of child's school:*
Does your child have health insurance?*

YesNo
If yes, who is your child's insurance carrier?*

MedicaidN/AOther
Has your child ever participated in Special Education or had a 504 plan?*

Yes, they participate in Special EducationYes, they have a 504 planNoOther
Has your child attended Freedom School before?*

YesNo
If yes, for how many years?
What are some strategies our team can use to best support your child's learning throughout the summer? (ex: positive reinforcement, small groups)*
Does your child have any allergies or health conditions of which we should be made aware? If yes, what?*
Is there anything else that you would like to share about your child?
Family Information

If requested information is not applicable or is unknown, please type N/A.
Name of person completing this form*

First NameLast Name
Relation to child:*
Are you the legal guardian of this child?*

YesNo
Your primary phone number*

Area CodePhone Number
Any other number where YOU can be reached

Area CodePhone Number
Is this number work/cell/etc
Email address you check frequently for Freedom School information throughout the summer*
example@example.com
How many people live in your household?*
Number of children age 6-18 in household*
Number of children age 5 and under in household*
Please indicate at least one way you plan to help support Freedom School this summer:*

I would like to be contacted to be a read aloud guest in the morningI would like to bring snacks for my scholar's class or entire siteI, or a group I belong to, would like to bring in breakfast or lunch for the siteI would like to bring in school supplies during the programI would like to lead a parent engagement nightI would like to chaperone a field trip

Please indicate which days/times will be best for you to attend parent engagement nights (at least one day is required):*

	Monday	Tuesday	Wednesday	Thursday	Friday
3:30pm
6:00pm
N/A

PRC application for reduced registration fee

This year, CDF Freedom Schools of Licking County is happy to have the opportunity to reduce the registration fee for some of our families!
The chart below will help determine whether or not your family meets the requirements. If your annual household income is 200% or less than the FPG guidelines, your family is eligible for PRC funding.

When considering annual income, please use GROSS annual income. Any child support you receive does not need to be included in this number.

If you are registering more than one child you do not need to fill out this section more than once.

Persons in Household - 200% of FPG (2020)
1 - $25,520
2 - $34,480
3 - $43,440
4 - $52,400
5 - $61,360
6 - $70,320
7 - $79,280
8 - $88,240

Add $4,480 for each person over 8 in household
My family meets PRC eligibility:*

Yes (if yes, please answer the below questions)No (if no, please proceed to the next section of the form)I have filled out this section on another child's form
PRC application requirements

If you answered yes to the previous question, please answer the following questions. This information will be used to complete a PRC application which will reduce the registration fee for your family.
Please verify the following information:

I am a US citizen or legal alienI am not a fugitive felonA minor child, or child age 18 and still attending high school, is living in the householdMy family’s income falls within the guidelines stated in the above chart
My family size is:
My family's gross monthly income (excluding child support) is:
Please list the names and birth dates of children from your family who will be attending Freedom School this summer:
Emergency contact & pick-up authorization:
Emergency Contact Information
Emergency contact's full name*

First NameLast Name
Relationship to child/family:*
Phone number*

Area CodePhone Number
Is this person authorized to pick up the child you enrolled in the program?*

YesNo
Pick-up Authorization

Please list other adults who are authorized to pick up the child you enrolled in the program.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child/family
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child/family
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child/family
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to child/family

Agreements & Signatures

By entering your first and last name under each agreement in this section you are signing this agreement electronically. By entering your first and last name you agree your electronic signature is the legal equivalent of your manual signature on these Agreements. By entering your first and last name, you consent to be legally bound by these Agreements' terms and conditions. If for any reason you do not consent to what the agreement says, please type "I do not consent" in the space for your name. Please be aware that in some instances not consenting to one of the below agreements could prevent the ability of your child to participate in the CDF Freedom Schools of Licking County program.
In case of an emergency, I give permission for any of the listed individuals to be contacted and my child may be released to them
Please type first and last name or "I do not consent"*
I understand that the organization that is enrolling my child in the CDF Freedom Schools® program is in partnership with the Children’s Defense Fund to offer this summer program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic information on children served and to report out this information in aggregate form.
Please type first and last name or "I do not consent."*
I give permission to the Children’s Defense Fund (“CDF”) and its designees to collect and record data on my child. This data gathering may include, but is not restricted to, the following:
- Surveys and/or interviews about his/her/their knowledge, attitudes, skills and behaviors in regard to his/her/their academic development such as motivation to read; nonacademic development such as leadership and conflict resolution skills; and overall satisfaction with the CDF Freedom Schools program.
- Academic assessments and school data from report cards.
These will be collected minimally twice: either shortly before the program begins, during the program, or shortly after the program ends. I understand that the purposes of these surveys and interviews are to document the impact of the CDF Freedom Schools program on its participants and to identify areas for improvement. I also understand that this information will remain private, and that only my childs site director(s) and research assistants approved by the Children’s Defense Fund will be able to look at his/her responses.

I also understand that my childs responses will be automatically grouped together with the responses of other CDF Freedom Schools sites for any public presentation of findings, and that my child will not be individually linked to his/her/their responses. In addition, I understand I can take back my permission at any time.
Please type first and last name or "I do not consent."*
I understand that the Children’s Defense Fund Freedom Schools program sponsored by CDF Freedom Schools of Licking County uses models, curriculum, and training provided by the Children’s Defense Fund (CDF). CDF seeks to ensure every child a Healthy Start, a Head Start, a Safe Start, a Fair Start and a Moral Start in life and successful passage to adulthood with the help of caring families and communities. I understand that a key goal of the CDF Freedom Schools® program is to involve parents in the life of the program as active participants in the learning experiences of their children. Because children do what we do and not what we say, I understand that all adults, including parents, guardians and adult family members of children enrolled in the CDF Freedom Schools program are expected to be positive role models, to communicate the importance of academic achievement, and to contribute to the creation of a caring and nurturing learning environment in which every child is valued and seen as capable of achieving. I agree that during the time my child is enrolled in the CDF Freedom Schools program, I and my family will:
- Volunteer in the school at least once a week
- Participate in weekly parent workshops
- Do our part to help make the CDF Freedom Schools program a caring and nurturing learning environment
- Ensure that my child is in attendance on a daily basis
Please type first and last name or "I do not consent."*
I hereby certify that the statements in this application are correct and true. I understand that my child’s enrollment as a CDF Freedom Schools student is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by the Children’s Defense Fund. I authorize the local program sponsor to furnish a copy of this form to the Children’s Defense Fund for use in any demographic/longitudinal evaluations that may be developed to strengthen the CDF Freedom Schools program nationally.
Please type first and last name or "I do not consent."*
Media Release Information

By entering your first and last name under each agreement in this section you are signing this agreement electronically. By entering your first and last name you agree your electronic signature is the legal equivalent of your manual signature on these Agreements. By selecting entering your first and last name, you consent to be legally bound by these Agreements' terms and conditions. If for any reason you do not consent to what the agreement says, please type "I do not consent" in the space for your name. Please be aware that in some instances not consenting to one of the below agreements could prevent the ability of your child to participate in the CDF Freedom Schools of Licking County program.
I hereby authorize and grant CDF Freedom Schools of Licking County and its agents and assigns the right to use the information I have provided in this enrollment form, and my oral and written comments about the program, for program publicity, grant requests, reports, and other purposes related to the promotion and advancement of the program in a way that does not personally identify myself or my family without my express written consent. I also authorize CDF Freedom Schools of Licking County to use images or videos of my child for local publicity and publicity to promote the program.
Please type first and last name or "I do not consent."*

My child's first name and last initial and/or last name may or may not be used in such publicity.*

	May	May not
First name ONLY
First name and last initial
First name and last name

By using my electronic signature, I consent to the usage of my child's name as I have indicated above.*
I hereby authorize and irrevocably grant to the Children’s Defense Fund and its affiliates, licensees, agents and assigns the unrestricted right to use and publish any part of the information that I have given to CDF and the right to record my name, voice, appearance, likeness and comments on film, videotape, audiotape, still photographs, print and any other media now known or hereafter invented. I acknowledge that CDF shall own all right, title and interest in and to this media. I further agree that CDF may cause all or parts of this media to be used for any and all publications, exhibitions, public displays, editorials, advertising or other purposes.I waive any inspection or approval of the media or any advertising or publicity in which my name, voice, appearance, likeness, narrative, or comments might appear. I expressly release and agree to hold harmless CDF and its agents, employees, licensees and assigns from and against any and all claims including, but not limited to, invasion of privacy that I might ever have in any way relating to my interview or its use.
Please type first and last name or "I do not consent."*

Registration Payment and Program Contribution

We are now able to process online payments for registration and donations.
A minimum registration fee of $25 per child is due at time of enrollment. If you are able to manage more, we invite you to make a donation in the name of your scholar, which will go toward general operating expenses of the program.

If your family qualifies for PRC funding, the reduced fee is $10 per child.
Payment amount

prevnext( X )
USDRegistration/donation
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CDF Freedom Schools of Licking County - 2020 Scholar Enrollment

Child Information

Family Information

PRC application for reduced registration fee

PRC application requirements

Emergency contact & pick-up authorization:

Emergency Contact Information

Pick-up Authorization

Agreements & Signatures

Media Release Information

Registration Payment and Program Contribution