TUB Application

Internet and Promotion

Student/Parent Agreement
As the parent or guardian for the aforementioned student, I do understand and agree to abide by the terms and conditions for use of the program based computers, all network and Internet systems, I further understand that violations of these terms of conditions may cause my students to forfeit further use of the technology provided by the program.

I understand that these access is designed solely for educational purposes and the program has taken reasonable precautions to supervise usage. I also recognize it possible for the school/camp to restrict unsupervised access to all information or material and I will not hold them responsible for materials acquired on the network. I also accept full responsibility for supervision of my child who may access the resources of the program from outside the program setting.

I also give permission to publish pictures and/or print work of or by my student that promote the best interest of the program and its accomplishments in or on:
- Dedicated web pages
- Newsletters
- Brochures
- Newspaper
- Cable television
- Other Media sources
Field Trip Permission Form
At Teen Up-Ward Bound students will be going on numerous field trips throughout the year. Field trips are an important part of our academic curriculum.

Given the frequency of our field trips, this form is to serve as permission for your child to attend all field trips scheduled by Teen Up-Ward Bound, Inc. Parents will be notified of all field trips date and times upon scheduling.

Please read the following and sign below indicating that you have read and accepted this policy. "I am the parent/guardian of the student below, and hereby give permission for him/her to participate in all field trips planned by the Teen Up-Ward Bound, Inc."
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Do you give Teen Up-Ward Bound, Inc to transport your child to special events (i.e. field trips) by private transportation, buses, staff accompanied walks, public transportation, vans or other automobiles.*

YesNo
In the case of injury or medical emergency, do you give Teen Up-Ward Bound, Inc permission to administer first aid, CPR, or call emergency medical services for your child? Do you authorize Teen Up-Ward Bound, Inc staff to provide any known medical history to medical staff and/or personnel.*

YesNo
I, parent/guardian* attest that all information provided is accurate and true to the best of my knowledge. I agree to inform Teen Up-Ward Bound, Inc of any changes in the above information within 24 hours of the change.
Name*

First NameLast Name
Signature*

Clear
Relationship to child*
Date*

MonthDayYear
Date

Authorization for Photography/Video
I, parent/guardian* the parent or guardian of child name* hereby authorize and give consent to service providers and the staff of The Children's Trust of Miami-Dade County as follows:
I hereby:

consent and authorizedo not consent and authorize
the staff of The Children's Trust of Miami-Dade County to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings (hereinafter "Recordings") of me, my children, or my wards for educational, research, documentary, and public relations purposes.
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Witness*

Clear
Date*

MonthDayYear
Date
Any such Recordings may reveal your identity through the image itself without any compensation to you, your children or wards.

Any and all Recordings taken of you, your children or words shall be the sole property of The Children's Trust.

With regard to the use of any Recordings taken of you, your children or words, you hereby waive any and all present and future claims you may have against The Children's Trust of Miami-Dade County, their staff, service providers, employees, agents, affiliates and Board members,

PERMISSION TO VIDEO OR RELEASE PICTURES

Often we take pictures of special events for the photo album and for special projects or the children are video taped interacting with each other and get to watch themselves on television. Please fill out this form stating whether or not your child is allowed to be photographed or taped.
I hereby*

givedo not give
Teen Up-Ward Bound, Inc permission to take pictures/video tape my child for program purposes only. student name* , while at Teen Up-Ward Bound, Inc I understand that these pictures/videos are for fun and will be done in a reasonable manner.

Emergency Contact Information
Parent/Guardian*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email*
example@example.com
Authorized Pick Up:
Unauthorized Pick Up:
Physicians Name
Phone
Please enter a valid phone number.
Insurance Carrier
Policy #
Have you/child previously attended Teen Up-Ward Bound?*

YesNo
Did you receive your parent handbook?*

YesNoInitial
Does your child have any known allergies?*

YesNo
If yes, please list allergies:
Do you give your child permission to leave Teen Up-Ward Bound, Inc without being signed out by an authorized adult and/ or to walk home?*

YesNo
If yes, sign and date below:

Clear
Date

MonthDayYear
Date
Should be Empty:

CHILD INFORMATION FORM

FOR STAFF USE ONLY (MUST BE COMPLETED)

Internet and Promotion

Field Trip Permission Form

Authorization for Photography/Video

Emergency Contact Information