"The following person/persons is/are authorized to pick up my child from the M.A.S.T.R. Kids program. I understand that the only person/persons listed below will be allowed to pick up my child or children."

PLEASE READ THIS CAREFULLY: SPPF is not a typical after care program. We are committed to the educational success of every child attending our SPPF: M.A.S.T.R. Kids programs. To truly have an impact, we need time with the students. This means that we expect outstanding and we require parents to pickup students after 5:45pm during the After-school Session or 4:00pm during the Summer Session. Frequent absences and/or frequent early pickups are disruptive to students achieving their goals and therefore may result in dismissal from the program.

I understand that SPPF requires time with students for impact. I agree to have my child attend whenever possible and I agree to pickup only after 5:45pm for the after school session and/or after 4:00pm during the summer session.

"My child/children has/have my permission to participate in the summer M.A.S.T.R. kids program. I also grant permission for the use of photos of my child/children to be used by The Shirley Proctor Puller Foundation and/or its agents for public relations purposes on behalf of M.A.S.T.R. Kids and The Shirley Proctor Puller Foundation."

"I understand that in the remote learning classrooms and programs, now and in the future, my scholar will be recorded as a regular course of business. I grant to the Shirley Proctor Puller Foundation the following rights in the interest enabling creation and distribution of informational and artistic materials:
1. The right to record my child’s image, photograph, picture, likeness, and voice by any technology or means.
2. The right to copy, use, perform, display and distribute such recordings of me for any legitimate non-profit purpose, including but not limited to distribution by means of streaming or other technologies via the Internet, or distribution of audio or video files (e.g. podcasts) for download by the public. I expect that care will be taken to protect the personal information of my child in connection with any such material.
3. The right to combine such recordings of my child with other images, recordings, or printed matter in the production of motion pictures, television tape, sound recordings, still photography, CD-ROM or any other media.
4. The right to use my child’s image and voice in connection with the marketing of SPPF’s programs, events, or educational or artistic materials.
I understand and agree that I will not receive compensation, now or in the future, in connection with SPPF’s exercise of the rights granted hereunder.

I hereby assign to SPPF any and all copyright I may have in the recordings made of me or my child hereunder."

"I acknowledge that the Juvenile Welfare Board of Pinellas County (“JWB”) provides funds to make the program or service in which I am participating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services.  

 By signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system, and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. §119.071). I acknowledge that as necessary to carry out the purposes listed herein, JWB may review all information about me, including my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB generally provides no direct services to me, except in certain circumstances may facilitate service delivery I further acknowledge that JWB does not provide medical diagnoses to me and JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act). 

 I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, to facilitate service delivery, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes of funded programs and services, and determination of future services/programs funded by JWB. I understand that the confidential information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of individuals in de-identified format, which means that no information that identifies me as an individual is revealed. 

 I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/ psychological/ substance abuse information from my medical health record, any information concerning the performance of any tests, results of those tests, and counseling and treatment records, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459, 381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I consent to my minor participating in online or paper surveys that will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization.

 I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a whole in de-identified format, which means that no information that identifies me as an individual is revealed. Except, JWB will not provide any records covered by CFR Title 42 to any JWB agents. 

I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program, or with respect to information used in research, or for compliance and quality review activities performed by JWB or its agents, upon completion of the last research project or compliance/ quality review, whatever occurs latest. By my signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below."

"I the undersigned parent/guardian hereby authorize M.A.S.T.R. Kids staff to sign for and authorize admission and treatment of the above-named minor for any emergency medical procedure deemed necessary by the medical staff. I also authorize the physician and medical staff to perform any emergency procedure necessary, and realize that such treatment, not covered by M.A.S.T.R. Kids/TSPPF insurance will be at my/our expense. I have read and thoroughly understand all of the above."

“ I certify, as the parent/ guardian of the child listed in this application, that all the information is true and all questions have been answered to the best of my ability.”