2019 Project Promise Summer Application

Family Information
Parent/Guardian Name *

Prefix First Name Last Name Suffix
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Employer *
Work Number *

Area Code Phone Number
Cell Number *

Area Code Phone Number
Email *
example@example.com
Parent/Guardian Name

Prefix First Name Last Name Suffix
Home Address

Street Address

Street Address Line 2

City State

Zip Code
Employer
Work Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Email
example@example.com
Student's Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Emergency Contacts

Authorized Person(s) Allowed to Pick Up Your Child
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to Student *
Is this contact authorized to pick up your child? *

Yes No
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student
Is this contact authorized to pick up your child?

Yes No
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student
Is this contact authorized to pick up your child?

Yes No
Is there any person NOT allowed to pick up your child?
Name

First Name Last Name
Relationship to Student
Describe:i.e. Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancel of
Name

First Name Last Name
Relationship to Student
Describe:i.e.Race, Height, Weight, and any Comments
Photo of Person NOT allowed to pick up your child.

Browse Files
File must be smaller than 10 MB. Cancel of

Medical Information
In case of emergency, Project Promise staff will call 911 and attempt to contact the parent/legal guardian and/or emergency contacts listed.

Please provide Project Promise with medical personnel contact information in case emegregency medical responders need it and contact cannot be made with parents/guardians.
Doctor's Name

First Name Last Name
Doctor's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Doctor's Phone Number

Area Code Phone Number
Insurance Company
Policy/Group Number
Name policy is under

First Name Last Name
Phone Number

Area Code Phone Number
List any Health Issues (Allergies, Vision, Hearing, Etc.) *
List any Dietary Restrictions (Allergies-Gluten, Dairy, Nuts, Etc.) *
Does your child take any medication? *

Yes No
If yes, please list.
What precautions or actions should be taken if medical care is needed? *
Are there any unusual factors in the child's life which the teacher or staff should be aware of? *
I give consent to Project Promise staff to apply provided sunscreen and/or bug spray for my child. *

Sunscreen only; please initial below. Bug spray only; please initial below. Both; please initial below. None
Initials

Privacy Rights & Authorizations
PRIVACY RIGHTS
I understand that pictures, and/or video will be taken during program activities/events. I give permission to Project Promise Summer Program and/or its Community Partners to use said photos/videos of my child, family and myself to be used in educational, promotional or informational materials or press media for public relations purposes. *

Yes; please initial below. No
Initials
I give consent to Project Promise Summer Program to contact me via my cellphone or my email provided within this application for updates pertaining to my child and program activities. (Project Promise Program will not share your email address with third parties without your consent.) *

Yes; please initial below. No
Initials
PERMISSION TO EVALUATE PROGRAMS AND TRACK STUDENT PROGRESS
I give permission for the Project Promise staff to review my child's school data (test scores, report cards, attendance, and other performance measures), for the purpose of providing targeted support, academic instruction and assessing the effectiveness of the Project Promise Summer Program. I also give permission for the Project Promise staff to monitor my child's progress and to require my child to complete evaluation surveys for the purpose of determining program effectiveness. *

Yes; please initial below. No
Initials
FLORIDA CHILD CARE STANDARDS AND STATUTES
- Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, "Know Your Child Care Facility" (CF/PI 175-24).
- Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility.

Project Promise K - 5

Family Information

Emergency Contacts

Medical Information

Privacy Rights & Authorizations

Program Expecations