Urban Ed Academy SMART+ Winter 2023

SMART+ Saturday Registration Form
Program Information:

The Urban Ed Academy SMART+ Saturday Program is FREE and open to all middle school students. Programming will be held from 9:00 AM - 3:00 PM at Wille L. Brown Jr. Middle School located in the Bay View area in San Francisco, CA. The children will participate in fun lessons and projects with the goal of helping them become their own entrepreneur. They will be introduced to successful, Black Business Owners to help guide them. Children will also explore hands on/interactive STEAM activities and outdoor/PE time. Lunch and snack will be provided. For program schedule and more information, please contact smartprogram@urbanedacademy.org or Program Coordinator, Samantha Vaing at Samantha@urbanedacademy.org.
STUDENT INFORMATION
Name*

First NameLast Name
Preferred Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Housing Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Home Language*
Race/Ethnicity*
Specify Ethnicity
Pronouns*

she, her, hershe, him, histhey, them, theirssie, hir, hirsOther
Grade*
School Attending*
Siblings enrolled in UEA programs (Names)
Student Allergies or Medication
PARENT/CAREGIVER INFORMATION
Name*

First NameLast Name
Relation to Student*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Communication*

Phone CallTextEmail
EMERGENCY CONTACT INFORMATION
Emergency Contact #1 Name*

First NameLast Name
Relation to Student*
Age (if under 18)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact #2*

First NameLast Name
Relation to Student*
Age (if under 18)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
STUDENT RELEASE INFORMATION
UEA staff are Mandated Reporters. UEA staff have the authority to observe the physical condition of the children, including conditions which could indicate abuse, neglect, or inappropriate placement, and to have a licensed medical professional physically examine the children.
Parent/Caregiver Initial*
Liability Release: In consideration of UEA allowing the Participant to participate in UEA programs I, the undersigned, do hereby release, forever discharge and agree to hold harmless UEA, its directors, employees, volunteers, partners, agents, officers, community monitors and coaches (collectively herein the “UEA”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities. I, the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and childcare, including trips away from the program premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said UEA for any liability sustained by said UEA as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
Parent/Caregiver Initial*
Restrictions: Providers who receive this information may not release it to someone else unless another authorization form is signed.
Parent/Caregiver Initial*
Your Rights: You may refuse to sign this form. You may cancel it at any time by informing the Urban Ed Academy in writing. If you cancel your permission to allow the release of information about you/your child, it will go into effect immediately (unless someone already released information). You have a right to receive a copy of this Authorization.
Parent/Caregiver Initial*
Medical Treatment Permission: I authorize an adult, in whose care the minor has
been entrusted, to consent to any emergency x-ray examination, anesthetic, medical,
surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the authorization.
Parent/Caregiver Initial*
Transportation Permission:UEA SMART+ programs use multiple methods of transportation for field trip activities/excursions. Transportation methods include but not limited to; School Bus, Approved Commercial Carriers (Charter Bus), Private Passenger Vehicles, Rental Vehicles (SUV's/Vans), Public Transit Authority (BART/Bus/MUNI) and walking. UEA SMART+ programs will obtain all vehicle service information, routes, departure and arrival schedules, etc. to share if necessary.

The undersigned hereby gives permission for my child/youth to ride in any vehicle driven by an approved and licensed adult while attending and participating in activities sponsored by UEA. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
Parent/Caregiver Initial*
Parent Agreement:
• If a parent has a problem with a student (which is not their own) they should not
approach the student. The parent should talk to the Director.
• If a parent has a problem with UEA Staff, they should not approach staff. The parent
should talk to the Director.
• If a parent violates any of the above policies, it is at the discretion of UEA staff to
decide the action taken, which could lead to suspension or expulsion of the student.
• I consent to my child being taken on field trips by UEA staff and am aware that this
sometimes involves taking public transportation.
• I agree to all policies stated in the Parent Handbook.
Parent/Caregiver Initial*
Consent to photo or video images of my child being used for promotional materials by UEA or organizations giving financial support to UEA.*

I do consentI do NOT consent
Permission for my child to sign themselves in, and out, of UEA programming.*

I do give permissionI do NOT give permission
How will they get home if they are signing out for themselves?
Alternative Pick up/Sign out Adult
PARENT/CAREGIVER VERIFICATION
Signature*

Clear
Should be Empty:

SMART+ Saturday Registration Form

Program Information:

STUDENT INFORMATION

PARENT/CAREGIVER INFORMATION

EMERGENCY CONTACT INFORMATION

STUDENT RELEASE INFORMATION

PARENT/CAREGIVER VERIFICATION