Resilient Kids Enrollment Form

After School Program

When: Starting September 20th, Tuesday-Thursday, 2:45 PM - 4:45 PM
Times are being finalized.

Where: The Rose Bowl 7419 E 11th St, Tulsa, OK 74112
Transportation available to the Rose Bowl from Bell, Lindbergh, & Mitchell Elementary schools

Who: K-5th Grade Students

Program Application
Only a parent or legal guardian can complete the registration form.
Are you the parent or legal guardian of this student? *

Yes No
Date *

Month Day Year
Date
Name of person completing this Registration Form *
Primary contact number? *

Area Code Phone Number
We will text you program information at this number.
Resilient Kids has three major goals for our students:

Goal 1: We want our students to grow in social/emotional awareness and regulation- this means becoming more aware of their body and emotions, and learning how to calm themselves when they feel upset or over-excited.

Goal 2: We want our students to grow in hope and resilience through supportive and safe spaces, fun activities, mentoring adults, and the story of Jesus.

Goal 3: We want our students to build and develop positive friendships with each other.
If your student is enrolled, would you share these goals for your student?

Yes No
**Important Note: After students are accepted into the program, over the first 3 weeks we will be evaluating whether Resilient Kids is a good fit for your student. Students who do best with 1 on 1 support may be invited to participate in our Care Groups program instead, where they can build important social and emotional skills with a trained adult mentor.**
Student 1 Information
Student 1 Name *

First Name Last Name
Birth Date *

Month Day Year
Date
School *
Explain Schooling Situation *
Grade (2022-2023 school year) *
Age *
Ethnicity
Gender *
Does your student have any behavioral challenges, learning disabilities, or any other diagnoses they have received from the school district? *
Does the student have an IEP? *

Yes No
Please explain what the IEP is for and what accommodations are included in the IEP?
What are your student's strengths? Is there anything your student especially enjoys doing? *
Has your student previously attended One Hope's Resilient Kids/getAHEAD program? *

Yes No
Student's T-Shirt Size *
Student's Street Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Would you like to enroll another student? *

Yes No
Student 2 Information
Student 2 Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Age *
School *
Explain Schooling Situation
Grade (2022-2023 school year) *
Ethnicity
Gender *
Does the student have an IEP? *

Yes No
Please explain what the IEP is for and what accommodations are included in the IEP?
Does your student have any behavioral challenges, learning disabilities, or any other diagnoses from the school district? *
What are your student's strengths? Is there anything your student especially enjoys doing? *
Has your student previously attended One Hope's Resilient Kids/getAHEAD program? *

Yes No
Student T-Shirt Size *
Would you like to enroll another student? *

Yes No
Student 3 Information
Student 3 Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Age *
School *
Explain Schooling Situation
Grade (2022-2023 school year) *
Ethnicity
Gender *
Does the student have an IEP? *

Yes No
Please explain what the IEP is for and what accommodations are included in the IEP?
Does your student have any behavioral challenges, learning disabilities, or any other diagnoses from the school district? *
What are your student's strengths? Is there anything your student especially enjoys doing? *
Has your student previously attended One Hope's Resilient Kids/getAHEAD program? *

Yes No
Student T-Shirt Size *
Caregiver Information
Your Name *

First Name Last Name
Your Street Address (if different from student's address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Your E-mail *
Emergency Contact 1
Name *

First Name Last Name
Relation to student?
Emergency Contact Phone Number *

Area Code Phone Number
Emergency Contact 2
Full Name *

First Name Last Name
Relation to student?
Emergency Contact 2 Phone Number *

Area Code Phone Number
Transportation From School to Resilient Kids
Which pick-up location will your student be at? Note: Families Choosing Self-transport must be able to commit to 80% attendance rate for their child (not counting excused absences).
Late Pick-Up Policy

Students must be picked up from the Rose Bowl between 4:45-5:00 PM or given permission to walk home.

Caregivers must arrange transportation for their students after Resilient Kids.
1. ANY CAREGIVER WHO WILL BE LATE MUST CALL.
2. We understand that unavoidable circumstances come up. Our goal is to support you and your students to the best of our ability. In the event that you will be late, we ask that you communicate with us as early as possible.
3. If no call was received prior to 5:00 p.m., the late fee will be assessed.
4. If a caregiver is late picking up their students a second time in a semester, regardless of a phone call, late fee charges will apply and must be paid within a one-week period. If the fees are not paid, the students will be unable to attend until the fees are paid or arrangements are made. The fees are used to compensate staff members who stay late to provide care for the students.
5. If a caregiver is late picking up their students a third time, in addition to the fee being charged, we will set a meeting with the caregiver to discuss how we can move forward.
6. Late Fee Schedule:
  - 5:05-5:25 $10.00
  - 5:25-5:45 $15.00
Do you agree to the late policy? *

Yes No
Do you understand that absences from Resilient Kids can result in your student losing his/her place in the program? *

Yes No
Please list the names of anyone who is authorized by you to pick-up the student from Resilient Kids. Parents/guardians and emergency contacts listed on this form may always pick-up students. Anyone picking up a student may be asked to show photo ID. *
Please list the names of anyone who is NOT authorized by you to pick-up the student from Resilient Kids. Parents/guardians and emergency contacts listed on this form may always pick-up students.
Does your student have permission to walk home from the Rose Bowl? *
Medical Information
Please list any of the following: current medications, medication allergies, food allergies, or chronic health concerns.
Authorization to administer the following non-prescription medication at Rose Bowl event. Please check all that apply.
Please check all that apply.

Tylenol Benadryl Ibuprofen Tums Neosporin Calamine lotion Cough drops Insulin shot Epi-pen I do not authorize Resilient Kids to give my child any medication.
Students must be toilet trained to participate in Resilient Kids. *

Yes, the student is toilet trained.
Is there anything else you would like us to know about your student?
Release Form for Minor
The undersigned is the parent or legal guardian of the Minor enrolling in Resilient Kids (hereinafter referred to as "Minor"). The undersigned desires for said Minor to attend and/or participate in ministries, events, programs, functions, and activities (hereinafter referred to as "Activity") sponsored by, connected with, or related to One Hope Tulsa, including but not limited to Resilient Kids, formal and informal. This includes transportation to and from such Activities. I understand and acknowledge that One Hope Tulsa will not allow the minor to participate in any Activity without releasing and holding One Hope Tulsa harmless from any liability arising out of the Minor's attendance and/or participation in that Activity, including the Minor's transportation to and from the Activity, if provided by One Hope Tulsa. I have or will investigate all risks involved with the Minor's attendance and/or participation in any Activity, and further, as the parent or legal guardian of said Minor, assume any and all risks of personal or bodily injury to said minor or property damages associated with said Activity. I understand that One Hope Tulsa does not bear any responsibility for the Minor's property if it is lost, stolen, or damaged during or as a result of his/her participation in Activities. By signing this document, on behalf of myself and the Minor, I hereby release and forever discharge One Hope, its officers, directors and employees, agents or any parties volunteering on behalf of One Hope Tulsa from all claims, damages, costs, or expenses of any kind arising out of or related to the Minor's attendance and/or participation in any Activity regardless of the specific cause thereof, and I further understand that in the event of such personal or bodily injury to the Minor, or property damage, that I cannot seek, on behalf of the Minor or myself, any type of recovery or reimbursement whatsoever from One Hope Tulsa or their officers, directors, employees, agents or any parties volunteering on behalf of One Hope Tulsa. It is understood that my student and I will abide by all policies of Resilient Kids and One Hope.
Consent *

I give my full and complete consent and agreement to the above Release Form for Minor.
Authorization and Consent for Medical Treatment
In the event my child becomes ill or injured, Resilient Kids is authorized to take one or more of the following actions:

a) provide first aid;
b) release my child to any of the people listed above;
c) take my child to the physician or call the physician indicated
d) take my child to a hospital and/or give consent for emergency care.
Consent *

I give my full and complete consent and agreement to the above Authorization and Consent for Medical Treatment.
Opportunity Project Consent

Part of our program is funded by the Opportunity Project, a Tulsa non-profit in charge of coordinating kids summer programs this year. As a funder, they require us to get consent for the following: (1) Do you consent to One Hope Tulsa sharing data from this registration form and from the Resilient Kids program with the Opportunity Project's database? (2) Do you consent to participate in surveys or assessments initiated by the Opportunity Project's team? (3) Do you acknowledge that the Opportunity Project may use video or photo media from this program?
Do you consent to the three statements above? *

Yes, I understand and give my consent
Media Release
I give One Hope Tulsa permission to do the following for non-profit use and without charge. At the discretion of One Hope Tulsa, photos, videos, stories, and/or audiotape that feature or include the Minor and work done by the Minor as well as the Minor's first name, may be used for the purpose of publicizing or promoting One Hope Tulsa. I understand that these photos, videos, stories, audiotape, work done by the Minor, and the Minor's first name may be published in newspapers, magazines, or on the Internet, may be broadcast on television or radio, may be utilized in fund raising efforts, and/or may be presented in informational, educational, or promotional materials or presentations.
Consent *

I give my full and complete consent and agreement to the above Media Release.
General Field Trip Consent

By checking the box, I give permission for my child to go on any and all field trips with Resilent Kids for the schoolyear term.

(I understand that I may withdraw this consent at any time by giving written notice to Resilient Kids, 7419 E 11th St. Tulsa, OK, 74112). I give the Resilient Kids/One Hope Tulsa staff and volunteers permission to transport my child to and from the field trip. If for any reason a medical emergency should occur, I authorize Resilient Kids/One Hope Tulsa staff and volunteers to secure medical care immediately. I understand that all expenses incurred in obtaining medical treatment will be my responsibility (not the responsibility of Resilient Kids/One Hope Tulsa and volunteers).
Consent *

I give my full and complete consent and agreement to the above General Field Trip Consent.
I give permission for my child to be transported to and from Resilient Kids and/or to and from events, activities, and field trips associated with One Hope, formal or informal. *

Yes
Note: Filling out this application does not guarantee your student(s) participation in our Resilient Kids After School Program.

If their age group is full, your student will be placed on our waitlist.
If you have any questions, please contact us.

Text or call the Rose Bowl with questions at 918-954-4147.
Should be Empty:

Opportunity Project Consent