BSDRT REGISTRATION FORM

BROTHERS & SISTERS DOING THE RIGHT THING INC.

AFTER-SCHOOL HOMEWORK / MENTORING
WHEN YOU HAVE COMPLETED THIS FORM, PLEASE PRINT AND NOTARIZE THE APPROPRIATE SECTIONS.
SEPTEMBER - MAY

Robert L. Taylor Community Complex - 1845 34th Street Sarasota, Florida 34234
Child's Name:
Age:
Gender:

MaleFemaleOther
D.O.B
School Currently Attending:
Grade:
Tutoring Needs:
Parent/Guardian Full Name:
Address:

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip:
Home Phone #:
Cell/Work #:
Special Medial Allergy Concerns:
BSDRT PROGRAM GUIDELINES/EXPECTATIONS

Please thoroughly read all accompanying application information below PLEASE PRINT AND NOTARIZE THIS SECTION OF THE FORM - INITIAL SECTIONS WHERE APPROPRIATE
Our homework /enrichment program is offered to students who have a sincere desire to gain and maintain academic success throughout the school year and beyond. There is no guarantee that our assistance will raise any child’s academic scores, but all efforts will be made in that direction to ensure progress. Students must follow these guidelines to be accepted in the program.

1. Regularly attend BSDRT afterschool program throughout the academic school year.

2. A requested $25 monthly donation to help with afterschool essentials.

3. Make an effort to do their very best work and be on their best behavior at all times.

4. Be considerate of BSDRT members, volunteers, students, and RLTCC staff. Any conduct that’s disruptive/ wasteful time or disrespectful to others will not be tolerated. If any of these acts occur, your child/children will be warned if continued parents will be called immediately with a written report and or suspension or dismissed due to disciplinary misconduct from the program.

5. Parents/guardians do agree not to allow children/children to the program if sick.

6. The parent/guardian agrees to call/inform BSDRT (Mrs. Alice Jones 941-544-3540) if the child/children they will be out for more than two days.

The undersigned parent/guardian does acknowledge that BSDRT homework assistance and mentoring provides this service to the community, therefore, any intentional and unlawful acts for the safety of the children and their well- being within the Robert L. Taylor Community Complex and Brothers and Sisters Doing the Right Thing Inc., program the responsibility is solely that of the parent/guardian. By signing below parent/guardian and child/children agree too and acknowledge the above guidelines.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Child/Children's Names:
(Personalized Seal) + Notary Public’s Signature

_______________________________________________________________

Alice F. Jones Founder and President, Dee Webber-vice President
PARENT/GUARDIAN RELEASE AND HOLD HARMLESS AGREEMENT FORM FOR STUDENT PARTICIPATION

PLEASE PRINT AND NOTARIZE THIS SECTION OF THE FORM INITIAL SECTIONS WHERE APPROPRIATE
I understand that Brothers and Sisters Doing the Right Thing (BSDRT) after-school homework assistance and mentoring program may participate in and /or conduct various activities and /or field trips to help educate and motivate the participating students. These activities and field trips are strictly voluntary.

Although BSDRT instructors are the individuals who facilitate and permit such voluntary participation, I/we ____________________________________________(parent/guardians) understand that I/we ________________________________________(parent/guardians) are solely responsible for any and all costs associated with any hazardous and poses a risk of injury conducted with the activities and/or field trips and that these voluntary activities and/or field trips are my/our _________________________________(parent/guardians) sole responsibility. Having read and understood the above, I/we __________________________(parent/guardians) give my/our permission for ______________________________________(son//daughter/ward) to participate in voluntary activities and/or field trips. I/we _________________________________________(parent/guardians) understand that BSDRT will use their vehicles or vehicles designated by BSDRT organization during such activities and /or field trips and agree for BSDRT to transport my/our son/ daughter/ward.

I/we fully understand that participating in these voluntary activities and/or field trips may be hazardous and poses a risk of injury. I/we hereby authorize BSDRT to conduct emergency medical services in the event of any injury. In consideration of permitting my/our son/ daughter/ward to participate in the various activities and/or field trips, permit to utilize facilities, services and programs of BSDRT for any purpose including but not limited to, observation use or use of facilities or equipment or participation in any off-site programs affiliated with BSDRT, the undersigned for himself and any personal representatives, executors and administrators, WAIVE, RELEASE, DISCHARGE AND COVENANTS NOT TO SUE BROTHERS and SISTERS DOING the RIGHT THING, Inc., and Robert L. Taylor Community Complex their directors, officers, employees and their agents for any and all injuries and other damages, which he/she may suffer in connection with his/her participation in the program or any other activities.

I/we agree to release and hold harmless BSDRT, its employees and agents from agree all claims, including but not limited to claims occurring from the negligence of BSDRT including attorney fees, resulting in any way from participation in any BSDRT activities. This release is freely and voluntarily executed by the undersigned after having carefully read it. I/we, in executing this release, have not relied on any inducements, promises, or representations by BSDRT or its agents not contained herein.
Sworn to and subscribed before me on the:

MonthDayYear
By:
Signature:

Clear
(Personalized Seal) + Notary Public’s Signature

_______________________________________________________________

Alice F. Jones Founder and President, Dee Webber-vice President
BROTHERS & SISTERS DOING THE RIGHT THING INC. MEDIA RELESASE FORM
2829 N. Gillespie Avenue. Sarasota, Florida 34234.

(941) 544-3540 or (941) 321-4131
We need student and parent permission to use any photograph, voice, and/or name in various promotional items. Please read the following, then date and sign where indicated thank you.

From time to time during the school year, newspapers and television stations, interviewing sessions, photography, and videotaping of our afterschool program, volunteers, and students to visually explain the many and varied types of programs and events which Brothers and Sisters Doing the Right Thing offer. Those photographs, videotapes, or audiotapes may be used in newspapers, on television, or in various publications and productions.

A parent or legal guardian's signature is required if the participant is under 18 years of age.

For more information, please contact:

Alice F. Jones, Founder, and President

Brothers and Sisters Doing the Right Thing Inc.

2829 North Gillespie Ave Sarasota, Florida 34234

Cell# (941) 544-3540

Email: ajdorightthing@gmail.com
If you do or do not want your child to be interviewed, photographed, or videotaped for such purposes, please answer below.

Yes – I hereby grant permission for my child to participate in the media activities described above for the opportunity and privilege of appearing in or participating in one or more video or audio recordings, photographs, films, or written articles, for BSDRT program.No – I do not consent to or want my child to participate in the media activities described above.
Student Name:

First NameLast Name
Grade:
Parent or legal guardian name:

First NameLast Name
Parent or legal guardian signature:

Clear
Date:

MonthDayYear
BROTHERS & SISTERS DOING THE RIGHT THING INC. TRANSPORTATION LIABILITY WAIVER

PLEASE PRINT AND NOTARIZE THIS SECTION OF THE FORM
As a parent/guardian of the child/children name below, I hereby release Brothers and Sisters Doing the Right Thing Inc., its agents, employees, volunteers, and trustees from any and all liability arising out of his/her transportation on the Harvest Tabernacle Bus to or from summer programs.

The utilization of this service shall in no way obligate Brothers and Sisters Doing the Right Thing organization for any reason. I understand that my full responsibility as a parent/guardian is to:

1. Instruct my child/children as to his/her pickup point.

OR

2. Make other transportation arrangements when there is no camp.
1st Child's Name:
2nd Child's Name:
3rd Child's Name:
4th Child's Name:
Signature

Clear
Sworn to me and subscrubed before me on the:

MonthDayYear
(Personalized Seal) + Notary Public’s Signature

_______________________________________________________________

Alice F. Jones Founder and President, Dee Webber-vice President
STUDENT/TEACHER/PARENT Conference Form
Note: Student/Parent/Teacher conferences may be used as an intervention prior to referral to BSDRT afterschool program recommended as part of a action plan.
School Name:
Date:

MonthDayYear
Student:
Grade:
Parent/Caregiver:
Language:
Parent Contact Information (telephone #):
Teacher(s) participating in conference (name and subject taught):
1)
2)
3)
Students Strengths:

Check all that apply
Asks for helpAttends class every dayComes prepared with materialsComes to class on timeCompletes HomeworkDoes well on testsGets along with other studentsHas a a postitve attitudeIs respectful towards adultsListens wellParticipates in classSolves ProblemsThinks Creatively
Other:
Concerns:

Needs
Attend School everydayBe on time to classBring all materialsRemain seated during classComplete class workParticipates appropriatelyCommunicates respectufllyHelp others as neededPositive attude toward learningPay attention, FocusComplete homework
Other:
SUGGESTIONS FOR PARENT/STUDENT:

8-10 hrs of sleep; alarm clock

Attend After-School tutorials

Check homework log daily

Clean up backpack/locker

Daily Progress Report

Enroll in an after-school program

Get health check-up & follow up

Get phone #s of study buddies

Healthy breakfast & lunch daily

Obtain counseling: academic/ social/emotional

Obtain/meet with an adult mentor

Reward small improvements

Student Attendance Review Team

Student Success Team

Weekly Progress Report
Comments/Concerns:
Parent/Caregiver signature:

Clear
Student:
Date:

MonthDayYear
BROTHERS & SISTERS DOING THE RIGHT THING INC. SCHOOL COMMUNICATION RELEASE FORM

“Children Are Our Top Priority”
School communication with parents/guardians is an essential part of every child’s education program and his/her road to success. Parents are also advised to keeping in close contact with the teachers and be available as soon as possible for meetings and/or phone conversations when teachers voice concerns.

Unfortunately, many parent/guardians meetings with teachers are not always convenient, Brothers and Sisters Doing the Right Thing (BSDRT) offer a stand-in service for parents who simply do not have a work or daytime schedule, to meet with their child’s teacher when requested.

Therefore, if a parent wishes, he/she may sign the following release below which will inform and allow a staff member or volunteer from (BSDRT) to visit their child’s school occasionally to meet with a child’s teacher. This release will inform both the school and teachers that they are free to voice concerns/problems regarding the child indicated below. Sarasota County school officials and BSDRT representatives will report these issues and work with parents/guardians in the hope of rectifying the situation.

Every parent/guardian is encouraged to attend school meetings and visitations themselves whenever possible. In the meantime, if you would like a staff member and volunteer to serve as a “STANDING” for you on your child’s behalf in educational settings, please sign below. This form of assistance will only be used when the parent/guardian sign below for BSDRT to act in on their behalf.
I give consent to BSDRT Staff Member/Volunteer:

YesNo
Child's Name:

First NameLast Name
School Attending:
Grade:
Parent/Guardian Name:

First NameLast Name
Phone/Home/Work#:
Cell#:
PLEASE REMEMBER TO PRINT AND NOTARIZE ALL APPROPRIATE SECTIONS OF THE FORM - INITIAL WHERE REQUIRED
Should be Empty:

BROTHERS & SISTERS DOING THE RIGHT THING INC.

SEPTEMBER - MAY

BSDRT PROGRAM GUIDELINES/EXPECTATIONS

PARENT/GUARDIAN RELEASE AND HOLD HARMLESS AGREEMENT FORM FOR STUDENT PARTICIPATION

BROTHERS & SISTERS DOING THE RIGHT THING INC. MEDIA RELESASE FORM

BROTHERS & SISTERS DOING THE RIGHT THING INC. TRANSPORTATION LIABILITY WAIVER

STUDENT/TEACHER/PARENT Conference Form

Students Strengths:

Concerns:

BROTHERS & SISTERS DOING THE RIGHT THING INC. SCHOOL COMMUNICATION RELEASE FORM