Emergency contacts are required and must not be the primary parent/guardian.
The East Atlanta Kids Club has an ongoing program to track the impact that our program may have on our child participants’ attendance, performance and behavior in school, as well as their behavior at Kids Club and in the community at large. In order to generate this data, we will request the following information on an annual or bi-annual basis. This information may be generated in written or oral form from you, your child, and the school system.
We will keep all records that we collect confidential. The data may be used or disclosed for research or statistical purposes. All reporting that results from this data will be completely anonymous, and will not include the names or any personally identifiable information about any child. Compliance with this request is voluntary and may be terminated at any time.
Your cooperation in our data collection program will be most appreciated.
I permit my child to participate in the East Atlanta Kids Club Summer Camp Program (hereafter “the Program”). I have read and understand the rules, regulations, and structure of the Program. I have met with an EAKC staff member to discuss my child’s participation. I understand that some of the people who serve as tutors and mentors in the Program are a mix of paid professionals and adult volunteers from the community who have been carefully screened by the organization. The meetings between my child and their tutors/mentors will take place both at the site of the Program (Brownwood Park Recreation Center) and off-site.
On some occasions, staff and/or volunteers will transport my child to and from the Program site and my child’s residence, as well as to and from field trip venues. I understand that all contacts between volunteers and my child are scheduled, monitored by EAKC staff, and evaluated. Any additional contacts between the adult mentors and my child/children must be scheduled in advance and be approved by me.
I understand that East Atlanta Kids Club is a free Program offered at no charge to children and their parents based on income eligibility guidelines provided by the Program. The Program does not require cash or in-kind donations or payments for youth whose families meet income eligibility guidelines provided by the Program.
I assume all risks and hazards incidental to the conduct of the Program activities. In the event of any injury or loss to my child, I hereby release, absolve, indemnify and hold harmless the East Atlanta Kids Club, the organizers of the activities, sponsors, supervisors, and volunteers, any and all of them.
I personally and hereby consent and authorize the release of educational information concerning my child (aforementioned in this application) to the EAST ATLANTA KIDS CLUB. This information includes: any and all records of the above-named child’s school attendance, grades, standardized test scores, conduct and disciplinary actions, for the past three school years, or for the time periods requested by EAST ATLANTA KIDS CLUB. Please provide such information to Ryan Downey, Executive Director, EAST ATLANTA KIDS CLUB, or their designees, at 602 Brownwood Avenue, SE, Atlanta, GA 30316. Phone: 404-627-8050.Please cooperate with EAST ATLANTA KIDS CLUB in securing the information requested.
This release is for all purposes and has an indefinite duration, unless otherwise limited herein. All other prior releases are hereby revoked unless noted as an exception herein. You are instructed that the release of this information pursuant to this authorization is not intended to alter, waive or destroy the confidential nature of information retained by you, nor to relieve you from continuing duties to safeguard such information. Photocopies of this release shall be deemed to be the original and the same consideration shall be given the photocopy as if the original was presented. Please be sure that any photocopies provided are readable copies.
This release may be revoked by me in writing. If you have any questions concerning this release, please contact EAST ATLANTA KIDS CLUB at the number and address above.
This health history is correct and complete as far as I know. The completed health information form may be printed/ photocopied for trips out of camp. I, the parent/guardian of the child named below, hereby give my permission for his/her participation in the East Atlanta Kids Club After-School Mentoring and/or Summer Camp program (the “Program”).
On behalf of my child, I assume all risks and hazards incidental to the conduct of the Program. In consideration of my child being permitted to participate in the Program, I hereby waive, release, discharge, indemnify, and hold harmless the East Atlanta Kids Club, its officers, directors, members, employees, and agents, as well as all organizers, sponsors, partners, supervisors, volunteers, and participants involved in the presentation of the Program, and each of their officers, directors, members, employees, and agents, from all liability for any damage, loss, or injury to person or property which may be sustained as a result of my child’s participation in the Program, even if such damage, loss, or injury is the result of negligence, in whole or in part, of any of these entities.
Further, I hereby give my permission to have my child treated on the scene and/or to take my child to a doctor or hospital in case of any injury at the Program.
I hereby acknowledge that I have carefully read and understand this Waiver and Release agreement and that I am freely and voluntarily signing it.