Pipeline Parent Application

Pipeline

Parent Application
Student's Name*

First NameLast Name
Student's Social Security Number*
No spaces. Ex: 123456789
Current Grade*
Current School*
Parent/Guardian Information
Guardian's Name*

First NameLast Name
Relation to child*

MotherFatherGrandparentGuardianOther
Phone Number*

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Has Guardian received a 4-year degree?*

YesNo
Guardian’s Name

First NameLast Name
Relation to child

MotherFatherGrandparentGuardianOther
Phone Number

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has Guardian received a 4-year degree?

YesNo
Email
example@example.com
The following financial statement is needed to prove income status, so that your student can participate in the program.
Number of people living in your household*
Including yourself
What is your yearly household income?*
Participant Confidentiality and Release of School Records
The Pipeline Program of Boys & Girls Clubs of the Tennessee Valley will maintain all student ﬁles in a conﬁdential manner. Pertinent information (i.e. all academic information, report card information or tutorial information) may be shared professionally with Pipeline staff members, or the school system child attends. Files for all programs grant funded in whole or in part are available for monitoring and subject to audit by the Boys & Girls Clubs of the Tennessee Valley grant program affiliates. Communication of student information to persons or agencies other than those listed above will require express written approval of the student’s parent.

A Pipeline staff person has explained the above information, regarding the release of information in my students file maintained by Pipeline of BGCTNV to me. I agree to the release of information to persona or agency as listed above. I understand that any release of information to personas or agencies other than those mentioned above will require my written approval.
Parent/Guardian's Signature

Clear
Date*
Media Publication and Release Authorization
I hereby grant Pipeline of BGCTNV full and absolute permission to publish, display, and use of photographs, together with descriptive test or statements, in which I or my child appear.
Parent/Guardian's Signature

Clear
Date*
Medical Information and Medical Consent

Please list any personal or family medical history that may be of importance to our records, including allergies and physician pre-scribed medicine that student is currently taking:
Medicines/Medical History
Allergies (and Allergic Reaction)
I authorize Pipeline staff to administer first aid that may include sunscreen, antibiotic ointment, Tylenol, bee sting ointment (or generic of each) in case of injury and/or secure or transport child for emergency medical treatment. (Every attempt will be made to contact parent. If any injury appears serious enough for hospitalization or medical care, such expenses will be borne by guardian or parent. I hereby authorize transportation to a medical facility and/or the calling of a physician at my expense to provide whatev-er emergency medical treatment is necessary.)
My child has permission to attend tutoring at (listed below) High School with PipeLine of Boys & Girls Clubs of the Tennessee Valley. By signing below I agree to the following terms: *
Name of High School
- Final decisions on tutoring sessions are at the advisor’s discretion
- My child must follow the guidelines set forth in the procedures for tutoring sessions
- I understand that I am responsible for my child’s transportation
Transportation Authorization
Please check one option: *

My child may be released only to me unless prior arrangements have been made with Pipeline staff.My child may be released to the following additional person/people:
Additional Person Authorized to Pick Up #1

Parent/GuardianEmergency
Name

First NameLast Name
Social Security Number
No spaces. Ex: 123456789
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Additional Person Authorized to Pick Up #2

Parent/GuardianEmergency
Name

First NameLast Name
Social Security Number
No spaces. Ex: 123456789
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Should be Empty:

Pipeline

Parent/Guardian Information

Participant Confidentiality and Release of School Records

Media Publication and Release Authorization

Medical Information and Medical Consent

Transportation Authorization