Giving Transformations for Opportunities Discoveries CDC
Student General Information
only one student per form
Student Name
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First Name
Last Name
Student Age
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Please Select
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Date of birth
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Month
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Day
Year
Date
Gender
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Male
Female
Other
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Student Backgrond Information
Name of School Attending
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Grade Level Current
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Please Select
Pre-K
K
1
2
3
4
5
6
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10
11
12
Grade Level Previous School Year
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Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Are there skills that need to be developed?
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Does the student have any learning accommodations at school? If yes, please explain accommodation and how long has the student been receiving this accommodation.
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With whom does the student live with? (check all that apply)
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Mother
Father
Stepdad
Stepmom
Grandmother
Grandfather
Other
Disability Status: You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabled? (please check)
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Yes
No
Disabilities include, but are not limited to: (check all that apply)
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/ AIDS
Schizrophrenia
Muscular distrophy
Bipolar disorder
Major depression
Mutiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive complusive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
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Primary Parent/ Guardian Information
Name
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First Name
Last Name
Age
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Gender
*
Male
Female
Other
Ethnicity
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American Indian or Alaska Native
Asian
Black or African American
Latino or Hispanic
Native American or Pacific Islander
White
Other
Disability Status: You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabled? (please check)
*
Yes
No
Disabilities include, but are not limited to: (check all that apply)
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/ AIDS
Schizrophrenia
Muscular distrophy
Bipolar disorder
Major depression
Mutiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive complusive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
Phone Number (primary)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (secondary)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
What is your prefrence for notifications and updates
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email
text
phone call
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Secondary Parent/ Guardian Information
Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Latino or Hispanic
Native American or Pacific Islander
White
Other
Marital Status
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Single
Married
Divorced
Disability Status: You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabled? (please check)
*
Yes
No
Disabilities include, but are not limited to: (check all that apply)
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/ AIDS
Schizrophrenia
Muscular distrophy
Bipolar disorder
Major depression
Mutiple sclerosis (MS)
Missing limbs or partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive complusive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental retardation)
Phone Number (primary)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (secondary)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Primary
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to student
*
Emergency Contact Secondary
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to student
*
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Additional Information
How did you hear about us?
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Flyer
Website
Instagram
Facebook
News Paper
Person to Person
Other
Please select your child’s academic strengths
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English
Reading
Math
Writing
Spelling
Social Studies
History
Science
Other
Please select your child’s academic weaknesses
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English
Reading
Math
Writing
Spelling
Social Studies
History
Science
Other
Within certain programs we will be providing meals for your child weekly, please list any food related allergies:
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe. Please list any medications that may be in their system while on site.
Please list the date and nature of any operations or serious injuries of the child.
Is the child prescribed an inhaler? If yes, please explain any instructions.
Does the child have any known disabilities and do they require any special accommodations?
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Who we are:
𝐆.𝐓.𝐎.𝐃. stands for 𝙂𝙞𝙫𝙞𝙣𝙜 𝙏𝙧𝙖𝙣𝙨𝙛𝙤𝙧𝙢𝙖𝙩𝙞𝙤𝙣 𝙊𝙥𝙥𝙤𝙧𝙩𝙪𝙣𝙞𝙩𝙮 𝘿𝙞𝙨𝙘𝙤𝙫𝙚𝙧𝙮. GTOD is a community development corporation (GTOD CDC) with a 501(C)3 designation, which is domiciled in the city of Hammond, Louisiana. GTOD was established in March of 1992, with the mission of helping transform individuals to discover life purpose
Age Guidelines:
GTOD is for children ages 6 to 18 (or high school seniors). Ages under 6 can be accepted under case by case criteria. Please contact program director for more information.
Medical Needs/Allergies:
G.T.O.D. learning outreach staff members are not permitted to administer medication to students. In the event of a medical emergency, G.T.O.D. counselors will administer first aid, CPR, and rescue in the best interest of the child. Parents will be contacted if care is administered.Allergy medications may be administered if directed in writing by the child’s parent/guardian. Special Circumstances: Parents and guardians are required to inform the G.T.O.D. staff in writing of any special circumferences which may affect the child’s ability to participate fully and within the guidelines of acceptable behavior, including, but not limited to, any serious behavioral problems or special circumstances regarding psychological, medical, or physical conditions. Once the notice is submitted, a conference will be scheduled with the parent/guardian to discuss the special circumstances and whether the program can accommodate the circumstances.
Personal Belongings:
Please put the child’s name on all articles of clothing, snack bags, bags, etc. Children should not bring toys, jewelry, money, or any possession of value with them to any of the programs. Children will be responsible for their belongings.
Behavior Management/Discipline Policy:
1. In the event a child’s behavior is a repeated behavior and cannot be corrected by the G.T.O.D Staff with a verbal warning or by restricting daily activities, a first incident report will be written to document the behavior. A copy of the report will be given to the parent/guardian the same day as the incident.
2. A second incident report will be written if the behavior is repeated or new behavior problems occur with the same child. This report will follow the same process as the first, but a one or two day suspension could accompany this report. A copy of the report will be given to the parent/guardian the same day as the second incident.
3. A third incident report will be completed using the same process as the first two. The G.T.O.D staff will write this report. Staff will provide this report to the parent/guardian. Incident reports will be discussed privately with a parent/guardian by a G.T.O.D staff member and Director. Dismissal from the program may occur at this time.
The G.T.O.D. staff will create a fun and safe learning environment for all students. Praise and positive reinforcement are used as effective methods of behavior management. Children who do not respond to these methods or who are destructive to others or to property will face professional discipline. The following procedures will be followed for behavior management. All incident reports will be discussed privately with parents/guardians and a copy of each report will be kept on file at the G.T.O.D tutoring site.
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Waivers and Informed Consent:
By checking below, I, as parent/guardian, permit the G.T.O.D organization and its affiliates to use pictures of my child (ren) as a program participant in promotional literature, videos, and websites. I understand my child (ren)’s name(s) will not be published. I, as parent/guardian of ______________________ (“Child”), hereby assume all risks and hazards incidental to the conduct of the activities at GTOD and transportation to and from the activities.
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Checking indicates that you have read, understand, and agree with the Policies and Procedures within GTOD.
Do you consent to use your child's progress as a testimonial to share and encourage other students?
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Yes I consent
No I do not consent
My Child is fit for the program(s) in which I have enrolled him/her. I HERELY RELEASE AND SHALL DEFEND, INDEMNIFY AND HOLD HARMLESS RELEASEES, G.T.O.D. CDC and its affiliates, FROM ANY AND ALL LIABILITY THAT I OR MY CHILD MAY ALLEGE AGAINST RELEASEES (including reasonable legal fees and costs) AS A DIRECT OR INDIRECT RESULT OF INJURY OR DEATH TO ME OR MY CHILD BECAUSE OF MY CHILD’S PARTICIPATION IN ANY G.T.O.D. PROGRAMS , WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES OR OTHERS TO THE MAXIMUM EXTENT PERMITTED BY LAW. I PROMISE NOT TO SUE RELEASEES ON MY BEHALF OR ON BEHALF OF MY CHILD REGARDING ANY CLAIM ARISING FROM OR RELATED TO MY CHILD’S PARTICIPATION IN ANY G.T.O.D. PROGRAM(S). I ACKNOWLEDGE THAT, BY SIGNING THIS DOCUMENT, I AM RELEASING G.T.O.D., THEIR REPRESENTATIVES, AGENTS, EMPLOYEES, VOLUNTEERS, MEMBERS, SPONSORS, PROMOTERS, AND AFFILIATES (COLLECTIVELY “RELEASEES”) FROM LIABILITY, AND THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS. THIS RELEASE FORM IS A CONTRACT WITH LEGAL AND BINDING CONSEQUENCES AND IT APPLIES TO ALL ACTIVITIES IN WHICH MY CHILD ENGAGES DURING THEIR PARTICIPATION IN THE PROGRAMS AT G.T.O.D., REGARDLESS OF WHETHER SUCH ACTIVITY IS A PART OF A FORMAL PROGRAM. I HAVE READ THIS RELEASE CAREFULLY BEFORE SIGNING. I UNDERSTAND WHAT THIS RELEASE MEANS AND WHAT I AM AGREEING TO BY SIGNING.
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Checking indicates that you have read, understand, and agree with the Policies and Procedures within GTOD and see your child as being fit for our program.
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