AFTER-SCHOOL ALL-STARS HAWAII REGISTRATION FORM

An emailed copy of this completed registration form will be sent to the Site Coordinator to register your student. You will receive a call or email to confirm that your student’s registration has been received.

Parent/Guardian 1 (will be contacted 1st in the case of an emergency and will be added to our Emergency Call and Reminder System)

Parent/Guardian 2

PLEASE NOTE IF YOU CHOOSE THE PICK UP OPTION, YOUR CHILD MUST BE PICKED UP PROMPTLY AT THE END OF PROGRAM

AS AN ORGANIZATION DEDICATED TO MENTORING AND MOLDING THE CHARACTER OF YOUNG PEOPLE, WE PLACE A SPECIAL EMPHASIS ON SELF-RESPECT AND RESPECTING OTHERS. WE BELIEVE IT IS OF THE UTMOST IMPORTANCE THAT YOU AS PARENTS/GUARDIANS ARE AWARE OF THE DISCIPLINE POLICIES AND PROCEDURES THAT HELP MAINTAIN A CULTURE OF RESPECT AND INTERGRITY. YOU MAY OBTAIN A COPY OF THE ASAS DISCIPLINE POLICIES, BY REQUEST, FROM THE ASAS SITE COORDINATOR.

I understand and support ASAS procedures as they pertain to student behavior, safety and conduct

I understand that attendance at ASAS programs is voluntary

I understand that it is my child’s responsibility to attend program

Parent liability/Parent authorization:

being allowed to participate in the After-School All-Stars (ASAS) Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. I certify that the above participant is in good physical and mental health and has never been declared medically ineligible from athletic competition. I further certify that the above mentioned participant has had no pre-existing medical condition or injury, listed as, but not limited to: exercise-induced asthma, cardiac or pulmonary (lung) disease, abnormal organ deficiencies, and head or neck injuries which may limit playing abilities; and,

2. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis, and death, and while particular skills, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and,

3. FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FORM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND ASSUME FULL RESPONISIBLITY FOR MY CHILD’S PARTICIPATION; and,

4. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and,

5. I, for myself and of behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMIFY AND HOLD HARMLESS ASAS, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners, and leasers of premises used for the activity (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABLITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Consent for treatment:

I understand that in case of emergencies, ASAS will make every effort to contact the parent(s)/guardian(s) before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by ASAS to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I (the parent/guardian) will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold the ASAS Site Coordinator, After School Staff and Youth Leaders, harmless there from.

I understand that it is my responsibility to review and complete the Brain Space Training Course resources provided by the Hawaii Concussion Awareness Management Program (HCAMP) and recommended by After-School All-Stars Hawaii (ASAS). I agree to support After-School All-Stars Hawaii in holding strict standards with regard to concussion management as per the standards established in the Hawaii Concussion Law Act 262.

Parental consent for photographs:

I hereby grant full permission to After-School All-Stars Hawaii to use my child’s photograph in videotapes, publications, motion pictures, recordings and all other events to be used solely for the purposes of After-School All-Stars Hawaii promotional material and publications, and waive any rights of compensation or ownership thereto.

Parental consent to access report cards and other school data:

I authorize the release of the following school information regarding my child to ASAS: (a) student identification number, (b) school attendance, (c)demographic data, including, but not limited to the participant’s race/ethnicity, whether the participant receives special education services, whether the participant is considered an English Language Learner and whether participant participates in the free or reduced priced lunch program, (d) achievement data, including but not limited, grades and standardized test scores, and (e) behavior data. Additionally, I understand that the information as noted above will only be shared with qualified professional staff from ASAS and with contracted third-party ASAS evaluators.

Consent for evaluation and/complete surveys:

I hereby give permission for my child and give consent for myself, as a parent or guardian, to participate in surveys and participate in evaluations that will be used to determine program effectiveness or to promote the program. I understand that my child’s and my answers to these surveys are strictly confidential.

I acknowledge that I have received, read, understand and agree to adhere to the After-School All-Stars Hawaii COVID-19 Policies and Procedures as outlined in the document provided.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments, and federal and state health agencies recommend social distancing and other preventative measures.

After-School All-Stars Hawaii (ASAS) has put in place preventative measures to reduce the spread of COVID-19; however, ASAS cannot guarantee that you or your child(ren) will not become infected with COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and/or I may be exposed to, or infected by, COVID-19 by attending ASAS programs and that such exposure or infection may result in personal injury, illness, permanent disability and/or death. I understand that the risk of becoming exposed to, or infected by, COVID-19 in ASAS programs may result from the actions, omissions, or negligence of myself and others, including, but not limited to, ASAS employees, volunteers and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and/or death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the ASAS program (“Claims” On my behalf, and on behalf of my children, I hereby release, agree not to sue, to discharge and hold harmless ASAS, its employees, agents and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions or negligence of the ASAS, its employees, agents and representatives, whether a COVID-19 infection occurs before, during or after participation in any ASAS program.

In an effort to prevent the spread of COVID-19 we have adopted policies and procedures to ensure all students/staff remain safe and healthy. After-School All-Stars Hawaii (ASAS) will be following standards, policies and procedures informed by the DOE, DOH and CDC. These are temporary measures and are subject to change at any time based on DOE, DOH and CDC recommendations/requirements.

•  ALL STAFF, STUDENTS AND VISITORS ARE REQUIRED TO WEAR A MASK IN INDOOR SETTINGS.
  • Students/families are required to provide their own masks. Important note:
    • Face shields are an added later of protection which can be worn in addition to a mask, but not as an alternative.
    • Exceptions - Medical Reasons (Doctorʻs Note Required)

• All ASAS staff members and students will be screened daily for temperature and symptoms. - Any student who has a temperature higher than (100.4°) or has flu-like symptoms, upon check-in, will be isolated in a low traffic area. Parents will be contacted and the student will be sent home, or parents will be required to pick them up, depending on the instructions provided on their registration forms. The school administration will be informed about any student sent home.
• Students will report directly to their designated after-school class at the end of the school day and adhere to social distancing guidelines as per markings laid out on the floor. Staff will provide guidance.
• Students will be allocated separate indoor/outdoor learning spaces and will be assigned to one group of students. Students will remain in this group for the duration of program. Group size will be determined according to appropriate safety guidelines, for social distancing, and the square footage of the specific indoor/outdoor learning spaces.
• Each staff member and student will wash their hands as frequently as possible (utilizing sanitizer as a secondary option) and at minimum during the following occurrences:
  • Before entering any program space
  • Before and after consuming food and beverages
  • Before and after using the restroom

• All visitors must report to ASAS office and wait outside for the Site Coordinator to meet them.

• Should a staff member of student display symptoms during program, they will be immediately isolated in a low traffic area. Parents will be contacted and the student will be sent home, or parents will be required to pick them up, depending on the instructions provided on their registration forms .
• A rea s where the symptomatic staff or student(s) were located will be thoroughly cleaned and saniti zed
• ASAS will inform the school administration of any staff or student ( s ) who were sent home due to displaying any symptoms .

• Students will be assigned one desk/table, distancing of same will be in keeping with HIDOE guidelines.
• Physical activities will be offered; however, students will be required to maintain all current HIDOE/DOH guidelines. No physical activity/sport that requires close contact will be permitted.

• Each program space will be equipped with the following:
  • Hand Sanitizer
  • Disinfecting wipes and spray
  • Gloves
  • Paper Towels
  • First-Aid Kit
• At the end of the day, under supervision, students will be responsible to wipe down their own desk/table and chairs.
• All door handles, light switches, whiteboards and common supplies will be wiped after the conclusion of each lesson.
• Bathroom:
  • Only one student will be permitted to use the bathroom at a time.
  • A staff member will disinfect the bathrooms at hourly intervals.
• All sinks and bathrooms will be thoroughly cleaned and disinfected at the end of each day.

• All snacks will be pre-packed in individual serving sizes
• Snacks:
  • Each student will have the opportunity to receive a free snack once per day
  • ONLY STAFF will be allowed to distribute snacks to students.

Our highest priority is the health and safety of your student. We thank you for trusting us with your student and are excited to have them in program. In the event in-person classes are not available, daily virtual afterschool programming will be provided. In addition, all families who choose to avail of distance learning can access virtual afterschool programming every school day.

If you have any further questions or concerns, please contact the Site Coordinator for more information.

Aloha After‐School All‐Stars Hawaii (ASAS) Parents and Guardians,

In order to provide your student athlete with the safest possible experience in our programs, ASAS practices strict adherence to concussion protocols. We see it as duty to inform students/parents/guardians of the risks associated with brain injuries as well as to provide information about an online training resource for you to stay informed about brain injuries, specifically concussions and the Hawaii Concussion Law.

• Education   of   parents,   athletes,   school   staff   and   administrators   and  sports officials
• Includes   youth   sports   from  11  years   old   and   above.
• Annual   training   of   coaches.
• Mandatory   immediate   removal   of   the   athlete   when   a   concussion   is   suspected.
• Need   for   clearance   to   return   to   play   by   a   licensed   health   care   provider   trained   in   concussion managemen t.
• Return   to   learn   and   gradual   return   to   play   protocols.

We would like to take this opportunity to inform you about an information resource and strongly suggest you take the time to become knowledgeable about brain injuries and concussion protocols.

Please find below a link to the Hawaii Concussion Awareness Management Program eucational course for parents. You will find this resource helpful in ensureing you and your student-athlete make informed decisions about staying safe in relation to concussions and potential brain injuries.

On completion of the course you will receive a downloadable certificate.

https://hawaiiconcussion.com/info?module=500.1&role=6