TEAMWorks Student Enrollment Form

Student Enrollment form

2021-2022 School Year
Child's Name

First NameLast Name
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Gender
Child's Date of Birth
Child's current grade level
Child's T-Shirt Size
Parent/ Guardian Information
Parent/ Guardian 1

First NameLast Name
Does this adult live at the same address as the child?
Relationship to the child:
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Parent/ Guardian 2

First NameLast Name
Does this adult live at the same address as the child?
Relationship to the child:
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact Information
Emergency Contact #1

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone

Area CodePhone Number
Emergency Contact #2

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone

Area CodePhone Number
Emergency Contact #3

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone

Area CodePhone Number
Medical
Does your child have a pediatrician or primary care doctor? Please give their name:
Doctor's Phone Number

Area CodePhone Number
Does your child have a dentist? Please give their name:
Dentist's Phone Number

Area CodePhone Number
List any food or environmental allergies your child has: if none write 'none'
List any special health or medical conditions your child has: if none write 'none'
Availability- Time Commitment
This school based program requires mentors to commit to being matched with a student for the duration of the school year (September through May), and to meet weekly at a designated time and place. Do your schedule and responsibilities allow for this commitment?
If No, Please explain:
Dismissal Instructions

At the conclusion of TEAMWorks (6:30)PM my child will be picked up by: please list those authorized to pick up your child. We cannot release your child to anyone who is not on this list. (This includes siblings)
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Legal
Does your child have a medication and/or care plan that is kept at school?
If yes, please explain:
Does your child have an IEP, academic or emotional or any other needs that we should know about?
Do you give permission for TEAMWorks and/or Pleasant Ridge Presbyterian Church to secure emergency transportation for your child in the event of an illness or injury WHICH REQUIRES EMERGENCY TREATMENT?
If NO, the following action should be taken: If you wrote Yes above type N/A
Program Permission and Authorization Form

school year 2021-2022
I give permission for my child to use all equipment and participate in all activities offered in the TEAMWorks program at Pleasant Ridge Presbyterian Church.
I give my permission for my child to meet weekly with a tutor/ mentor as a part of the TEAMWorks program. Tutor/mentor and student interactions take place in a group setting. Mentors/tutors will not contact students or families outside of TEAMWorks/ PRM. Students may receive written letters from their mentors/tutors that are forwarded to their homes by TEAMWorks staff.
I give permission for PRM to release academic records including IEP's, grades, test scores and attendance information to TEAMWorks.
I give permission for TEAMWorks staff to take whatever steps they deem medically necessary to obtain emergency medical care, as warranted in the Ohio Department of Job and Family Services required enrollment form.
I understand that children are NOT permitted to use cellphones during TEAMWorks program hours and that cellphones will be kept in a locked room for safe keeping. PLEASE CONTACT TEAMWORKS STAFF DURING PROGRAM TIME TO COMMUNICATE WITH YOUR CHILD IF NEEDED.
I understand that children who are absent from school may NOT attend TEAMWorks that day.
I understand that if my child has a medical condition, s/he must have a care plan and/or medicine at TEAMWorks.
TEAMWorks staff, program and collaborators are not responsible for anything that may happen as a result of false information given by a parent/ guardian.
Expenses incurred in obtaining medical treatment are the responsibility of the parent/guardian.
The TEAMWorks program and its collaborators prohibit staff and volunteers from spending time outside of the program with children they have met in the program.
The TEAMWorks program and its collaborators will not assume responsibility for any child who has not been signed in on arrival or who has already been signed out for departure.
Pick up is at 6:30. Please come inside to pick up your child and sign them out and pick up your hot family meal. TEAMWorks is dedicated to helping families eat a family meal together. To achieve this goal we are partnering with La Soupe to provide each child's family with a hot meal ready to eat when they get home after TEAMWorks.
Only those who are listed on this form may pick up a child from TEAMWorks. Staff will not release a child to anyone other than the parent/guardian of record, or a person authorized by the parent/guardian. Any authorized person who is unknown to staff will be required to present photo identification.
If a person who appears to be under the influence of drugs or alcohol arrives to pick up a child and is unable to safely supervise the child or is planning to drive a motor vehicle, staff will contact the child's emergency contacts and/or law enforcement personnel as determined by the staff member's judgement.
Staff members of TEAMWorks are mandated by law to report any suspected cases of child abuse or neglect to appropriate authorities.
By enrolling my child in TEAMWorks I am choosing this arts and academic program for my child over all other after school options on Wednesday afternoons. I will make it a priority for my child to be at TEAMWorks each time they meet.

Other
I give my permission for TEAMWorks and its program collaborators to take, use, display and publish my child's photo in connection with the public relations activities connected with this program. I waive all claims for any compensation for such use or for damages.
Home Life and Hobbies

More about my Child
My child is happiest when s/he is blanks . His/her favorite thing about school is blank .
At home my child likes to blanks. My child is good at blank .
Additional Information
Does your family have religious or cultural traditions and practices we should know about to better care for your child?
Is there anything else that you'd like us to know about your Child or your family?
This information is true and correct to the best of my knowledge and information. Signature
Should be Empty:

Student Enrollment form

Parent/ Guardian Information

Emergency Contact Information

Medical

Availability- Time Commitment

Dismissal Instructions

Legal

Program Permission and Authorization Form

Home Life and Hobbies

Additional Information