Innovation Boulevard Registration Form

INNOVATION BOULEVARD

Afterschool & Summer Registration

Produced by

The Diversity & Innovation Institute

in partnership with

The Metropolitan School District of Lawrence Township
Innovation Boulevard (iBlvd) is an afterschool program provided by the Diversity & Innovation Institute (DNOVA) and MSDLT at Belzer and Fall Creek Valley Middle Schools.

To register, parents/guardians must complete this form. If you are registering more than one participant, please submit a separate form for each child. You may save your progress and return to this form at any time by clicking the button at the bottom of this page.
Please select the terms you would like to enroll your student in (if you are a high school student interested in joining the iBlvd team, please select Program Assistant):*

Spring 2025Summer 2025

Emergency Contact Information

In an emergency, one or more of the contacts listed below will be alerted using the information provided below.
Contact 1 Name:*
Contact 1 Relationship to Minor:*
Contact 1 Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact 1 Daytime Phone*
Please enter a valid phone number.
Contact 1 Evening Phone:
Please enter a valid phone number.
Contact 2 Name:*
Contact 2 Relationship to Minor:*
Contact 2 Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact 2 Daytime Phone:*
Please enter a valid phone number.
Contact 2 Evening Phone:
Please enter a valid phone number.

Medical Information
Has your child received the COVID-19 vaccine?*

YesNoPrefer not to answer
Allergies / Dietary Considerations:*
Please share any allergies or dietary considerations we should be aware of.
Date of last Tetanus Toxoid Vaccine:

MonthDayYear
Past Health/Injuries:
Please share any past health conditions that we should be aware of.
Present Health Conditions:
Please share any present health conditions that we should be aware of.
Current Medications Taken by Participant:
Other information that would be relevant in the event of emergency medical treatment:

Insurance Information

Parents or legal guardians are responsible for the cost of a minor's medical treatment. When available, insurance information will be processed by the health facility performing the treatment; otherwise you will be contacted for payment by cash, check, or credit card.
Insurance Company:
Policy Holder's Name:
Policy Number:
Member ID:
Policy Holder Address:

Street Address

Street Address Line 2

CityState

Zip Code
Policy Holder's Relationship to Minor

Consent for Medical Treatment of a Minor
I, as the parent or legal guardian of the aforementioned Innovation Boulevard Participant, grant the following authorization for medical and/or surgical treatment of this minor by a health care professional should the need arise while they are attending the Innovation Boulevard program.
Please check and complete one (1) of the following:*

I grant permission to the directors, assistants, or other persons responsible for her/his care to act on my behalf for said minor in granting permission for evaluation and treatment of medical or psychological problems. I understand that should a major medical or psychological problem arise; reasonable attempts will be made to notify me by telephone. In the event that I cannot be reached, I give my consent to such medical treatment as deemed necessary, including surgery, x-ray examinations, and anesthesia to be rendered to said minor by a licensed physician or nurse.I do not wish medical care of any kind, except in case of an emergency.I authorize limited medical care specified below:
If authorizing limited medical care (checked above), please provide details of limited authorized medical care:
Signature for Medical Care Authorization*

Clear
Date*

MonthDayYear
Date
Note: Innovation Boulevard staff members are unable to administer medication. If a minor cannot self-medicate, a parent/guardian must come to the program to administer any required medications.

Consent and Release Form for Interviewing, Photographing and Videotaping

I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images”), and authorize the Diversity & Innovation Institute and companies with whom it collaborates (collectively, “DNOVA”) to use, release, publish, exhibit, post on the Internet, in CD-ROMs or any other medium any of my Personal Images, as described below and understand and acknowledge by signing this consent form the following:

By signing this form, I hereby give permission to DNOVA to use my Personal Images in whatever medium deemed appropriate by DNOVA for any of the following purposes: (i) public relations; (ii) marketing & social media; and (iii) training & education. DNOVA will not use the Personal Images for any other purposes.
- I understand that my Personal Images may be seen and used by DNOVA throughout the world and hereby give consent to such worldwide use for the purposes stated in this consent form.
- I understand that my consent is voluntary, that I am not required to sign this consent and that I may in fact refuse to sign it, thereby prohibiting DNOVA from obtaining or using any Personal Images of me.
- I have the right to revoke my consent at any time, which revocation must be in writing and submitted to DNOVA at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268; or via email at iblvd@dnova.org.
- I release and discharge DNOVA, its officers, agents and employees, and each and all persons involved in creating my Personal Images from any liability connected with the taking, recording, filming or publication of said interviews, photographs, slides, computer images, videotapes or voice recordings.
- I waive all rights I may have to claims for payment or royalties in connection with any exhibition, televising, internet posting, or other publication of my Personal Images, irrespective of whether a fee for its use is charged by any third party.
If I have any questions about my privacy rights under this form, I understand that I may contact DNOVA at 317-703-7836 or by writing at the following address: the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268, or by emailing to iblvd@dnova.org.
If the subject of the personal images is under 18 years old, the parent or legal guardian must sign below.

By signing this Consent and Release Form, I consent to allow the minor named below to participate in the activities described above and allow the information obtained from the below named minor to be used and shared as described above. I represent and warrant that (i) I am eighteen (18) years of age or older and am legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the legal authority to represent the below named minor (iii) I have read and understand this Consent and Release Form and (iv) I have had an opportunity to ask questions about the use of the below named minor’s Personal Images, understand their purported use, knowingly consent to such use and voluntarily sign this Consent and Release Form on behalf of the below named minor.

You may request a copy of this Consent and Release Form by emailing iblvd@dnova.org.
Consent:*

I consent to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United States)"I do not consent to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United States)"
Name of Minor:*

I consent to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United States)"I do not consent to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United States)"
Name of Parent/Guardian:*
Signature of Parent/Guardian:*

Clear
example@example.com
Date*

MonthDayYear
Date
If the subject of the personal images is 13 to 17 years old, they are required to acknowledge that their participation is voluntary by signing below.

You do not have to do this. No one will be mad at you if you refuse to do this or if you decide to quit.

As stated below, I willingly agree to participate in this project. I understand that my image and personal information may be displayed globally via the means described previously.

Fill this section if consenting to the "Consent and Release Form for Interviewing, Photographing and Videotaping (United States)".
Name of Participant:*
Signature of Participant:*

Clear
Participant Address:*
Participant Phone:*
Please enter a valid phone number.
Participant Email:*
Date*

MonthDayYear
Date

FERPA Release
Participant Information
Participant Name*

First NameMiddle NameLast Name
Participant Date of Birth*

MonthDayYear
Date
Participant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
FERPA Resources
What is FERPA?

The Family Educational Rights and Privacy Act (FERPA) is a federal law that affords parents the right to have access to their children’s education records, the right to seek to have the records amended, and the right to have some control over the disclosure of personally identifiable information from the education records. When a student turns 18 years old, or enters a postsecondary institution at any age, the rights under FERPA transfer from the parents to the student (“eligible student”). The FERPA statute is found at 20 U.S.C. § 1232g and the FERPA regulations are found at 34 CFR Part 99.

What is an education record?

"Education records" are records that are directly related to a student and that are maintained by an educational agency or institution or a party acting for or on behalf of the agency or institution. These records include but are not limited to grades, transcripts, class lists, student course schedules, health records (at the K-12 level), student financial information (at the postsecondary level), and student discipline files. The information may be recorded in any way, including, but not limited to, handwriting, print, computer media, videotape, audiotape, film, microfilm, microfiche, and e-mail.

Source: 34 CFR § 99.2

A Parent's Guide to FERPA can be found at:

https://studentprivacy.ed.gov/resources/ferpa-general-guidance-parents

Students and parents find more information about protecting student privacy at:

https://studentprivacy.ed.gov/audience/parents-and-students

The entire Family Educational Rights and Privacy Act can be found at:

https://studentprivacy.ed.gov/node/548/#0.1_se34.1.99_11
Use of Education Records by Innovation Boulevard
The Innovation Boulevard Program, as an academic enrichment program, must make use of private student information in order to effectively fulfill its mission. In pursuit of that mission, the Diversity & Innovation Institute will share student information provided by the Metropolitan School District of Lawrence Township with partner organizations who directly support Innovation Boulevard and its participants, including the Department of Education’s 21st Century Community Learning Centers program.

If you have any questions or hesitations, please feel free to contact the Innovation Boulevard Program Manager, Christelle Mutombo, at iblvd@dnova.org, or at 317-679-2466, or at the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268.
Consent
I hereby exercise on behalf of my child the release of his/her academic records in the custody of the Metropolitan School District of Lawrence Township to the Diversity & Innovation Institute and Innovation Boulevard partners.I do not exercise on behalf of my child the release of his/her academic records in the custody of the Metropolitan School District of Lawrence Township to the Diversity & Innovation Institute and Innovation Boulevard partners.
This Consent is effective for the following period unless otherwise revoked:
Date Effective From*

MonthDayYear
Please enter the first date participant will attend the program
Date Effective Until*

MonthDayYear
Name of Signatory*

First NameLast Name
The Innovation Boulevard Program, as an academic enrichment program, must make use of private student information in order to effectively fulfill its mission. In pursuit of that mission, the Diversity & Innovation Institute will share student information provided by the Metropolitan School District of Lawrence Township with partner organizations who directly support Innovation Boulevard and its participants, including the Department of Education’s 21st Century Community Learning Centers program.

If you have any questions or hesitations, please feel free to contact the Innovation Boulevard Program Manager, Matt DeLoughery, at iblvd@dnova.org, or at 317-703-7836, or at the Diversity & Innovation Institute, 9100 Purdue Road, Suite 410, Indianapolis, IN 46268.
Signature*

Clear
Date Signed*

MonthDayYear

Participant Signature

I hereby agree to the Innovation Boulevard Behavior Policy and other terms (consent forms and waivers) in this document and the Innovation Boulevard Family Handbook for my participation in the Innovation Boulevard program.

I have reviewed, agreed to, and completed all necessary information needed.
The undersigned assumes full responsibility for the risk of bodily injury and death, whether due to the negligence or gross negligence of the Released Parties or otherwise. The undersigned voluntarily accepts those risks. We understand that this Release includes all claims based on actions, omissions, negligence or gross negligence of the Diversity & Innovation Institute, whether a COVID-19 infection occurs before, during or after participation with Innovation Boulevard Program. We understand that it is our sole and exclusive responsibility to purchase health insurance and agree to be liable for and pay all costs and expenses incurred with any medical and/or hospital services rendered to the undersigned, my child and/or children and/or family as a result of any activities associated with the Diversity & Innovation Institute.

The undersigned acknowledges that this Release, Waiver, Assumption of Risk and Indemnification Agreement is intended to be as broad and inclusive as permitted by law, and that if any portion of this Agreement is held to be invalid, it is agreed that the balance of the Agreement shall; notwithstanding, continue in full legal force and effect.

The undersigned acknowledges that he/she has carefully read the above Agreement and knows and understands its contents, knows and understands that by signing this Agreement, he/she voluntarily gives up substantial rights and assumes the risk of injury and/or death for the minor child and/or children and signs this Agreement as his/her own free act.
No student will be allowed to participate unless this form is completely filled-out and signed by the participant and a parent or guardian.

The Program reserves the right, upon notification of parents, to send home any student during any session for improper dress, conduct, language, or attitude which, in the judgment of the administrative or counseling staff, is deemed detrimental to the other students or smooth operation of the program. Furthermore, if in the judgment of the administrative or coordinating staff, the student’s conduct violates any of the rules and regulations, the student will be sent home and referred to appropriate authorities.
Date*

MonthDayYear
Participant Signature*

Clear
Parent/Guardian Signature*

Clear

Innovation Boulevard Family Handbook

Parent/Guardian Acknowledgement Form

The Diversity & Innovation Institute’s Innovation Boulevard program is offered free of charge thanks to a 21st CCLC federal grant administered by the Indiana Department of Education. The program offers academic support, academic enrichment, college and career readiness, and recreational opportunities for students, and it also serves students’ families. To get the full benefit of the program, your child should attend daily for at least 65 days. Students who do not attend regularly and meet the 65 day minimum attendance requirement may be dismissed from the program so students on the waitlist may have this opportunity.

Family group activities will be offered throughout the semester during “Family Nights”. All family members are eagerly invited to join! Your child and family are expected to meet program guidelines and participate regularly. Instructors use positive reinforcement during the afterschool program to keep a positive and fun learning environment. To maintain that positive environment, we will not allow harassment or bullying. We have a “zero tolerance” policy for any weapons or controlled substances. We expect the participants to follow the expectations and procedures described in the Innovation Boulevard Family Handbook and the MSDLT Middle School Student Handbook (https://www.ltschools.org/parents). Expectations during the afterschool program are the same as during the regular school day. Our behavior/discipline policy states that if a student has a discipline issue, the parent or guardian will receive a copy of the incident report. If your child receives three of these forms, they may be suspended from the program for three to five days. The fourth notice may result in termination from our program. We reserve the right to suspend or terminate a student from the program immediately if a student’s behavior puts staff or other students in danger. Please refer to the MSDLT Middle School Student Handbook or contact the site coordinator for more information. The program hours go from school dismissal (3:45 p.m.) until 6:15 p.m. Monday through Thursday. On days when school is not in session, there will be no program activities. Innovation Boulevard will follow the MSDLT academic calendar. We will not provide afternoon/evening services on early release days.

Please read and discuss the Family Handbook with the participant. A signed copy of this form, as well as the registration form, must be turned in to the Innovation Boulevard team. Hard copies will be available on-site, and a link to an electronic version will be made available to all parents through the Band App and on the program’s website.
Student Name:*
School:*
Parent/Guardian Name:*
Encabezado
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Participant's Information

Demographics

Parent / Guardian Information

Program Information:

FERPA Release

Participant Information

Parent/Guardian Information

FERPA Resources

Use of Education Records by Innovation Boulevard

Consent

Encabezado