Jasper's Corner Tutee Intake Form

Jasper's Corner Registration Form

Please submit this form to complete your student's registration for Jasper's Corner. Please limit one Registration Form for per child. There are three locations for Jasper's Corner: A. K. Smiley Public Library (high school and middle school students only), Redlands Community Center (1st-12th) and University of Redlands-Armacost Library (1st-12th). Completing this form does not guarantee placement in the program. Once a spot is available, you will be contacted by our team regarding placement of your student. Contact the Community Service-Learning Office at csl_office@redlands.edu, with any concerns.
Child Participant Information
Child Name*

First NameLast Name
Date of Birth*
Age*
T-Shirt Size*
Grade Level*
School District*
Current School*
Languages Spoken at Home*
Please indicate your preference for location of Jasper's Corner tutoring*

University of Redlands-Armacost Library 3rd floorRedlands Community Center 111 W. Lugonia Avenue, Redlands 92374A.K. Smiley Public Library (high school & middle school students) 125 W Vine St., Redlands, CA 92373
Which days would your child be available for tutoring?*

MondayTuesdayWednesdayThursday
Family Information
Street Address*
City*
Zip Code*

Family Contact Information

Please list the name, phone number, and email of the primary person we should contact with program updates, and in case of an emergency.
Guardian Name*

First NameLast Name
Relationship to Child*
Cell*
Email*
all of our communication will be email, unless an emergency occurs.
Emergency Contact Information

Please list the names and contact information of three other people who we can contact in case of an emergency.
Contact 1 Name*

First NameLast Name
Contact 1 Relationship to Child*
Contact 1 Cell Number*
Contact 1 Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this person allowed to pick up/drop off your child at the program location?*

YesNo
Contact 2 Name*

First NameLast Name
Contact 2 Relationship to Child*
Contact 2 Cell Number*
Contact 2 Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this person allowed to pick up/drop off your child at the program location?*

YesNo
Contact 3 Name*

First NameLast Name
Contact 3 Relationship to Child*
Contact 3 Cell Number*
Contact 3 Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this person allowed to pick up/drop off your child at the program location?*

YesNo

Medical Authorization

Please note: The University of Redlands does not provide medical insurance to cover medical care for minors participating in University-sponsored programs.
Health insurance company*
Health insurance policy number*
I authorize the release of medical information (HIPPA) and emergency treatment in case myself, or any emergency contacts, cannot be reached for permission. *

Clear
Please list any physical, mental, or medical conditions your child has, including any allergies that could impact their participation in the program. *
Does your child have any food allergies? If so, please explain. *
Will program staff need to administer any medications to your child? If yes, please list medication & instructions. *
Is your child allowed to administer any of their own medications (provided by a parent or legal guardian)? If yes, please list medication and instructions. *
Does your child wear contact lenses?*

YesNo

Waivers and Release Forms

Please review our parent/guardian handout to review our program rules and policies.
My signature below indicates my understanding of the policies and procedures outlined above for this upcoming year. Should my child have more than two unexcused absences I understand they risk being dismissed from the program.
I, blanks*, hereby understand that the attendance policy will be enforced, and failure of (child's name) blank* to come to scheduled program sessions could lead removal from the program.
Date*
Signature*

Clear
Mandated Reporting
All University of Redlands students working for Jasper's Corner are mandated reporters. A mandated reporter is required by law to report known or suspected abuse or neglect relating to children. Please sign to indicate your understanding that program staff are mandated reporters. *

Clear
Image Consent and Release

(optional)
I hereby consent to and authorize the use and reproduction, in print or electronic format by the University of Redlands ("University") or anyone authorized by the University, of any and all audio, video, or photographic images, which have been taken for any publicity purpose, without compensation.
All audio, video, or photographic images - electronic, negative, and positives, together with the prints - are owned by the University. The authorization is continuous and may only be withdrawn by my specific rescission of this authorization. I release all claims against the University with respect to copyright ownership and publication including any claim for compensation related to use of the materials. I hereby hold harmless and release and forever discharge the university from all claims, demands, and cause of action which I, my heirs, representatives, executor, administrators, or any other persons acting on my behalf of my state have or may have by reason of authorization.
I hereby acknowledge that I am 18 years of age or older, or am the legal guardian of (child's name) blanks and have read and fully understand the terms and contents of this release.
Date
Signature

Clear
I do not give consent for the use and reproduction, in print or electronic format by the University of Redlands ("University") or anyone authorized by the University, of any and all audio, video, or photographic images, which have been taken from any publicity purpose, without compensation

Check here if you choose not to image release your child
University of Redlands Children's Program Agreement
Please Review the following and check each box and sign the agreement indicating the mutual support, commitment, and understanding of the program. Thank you! *
I, the parent or guardian of blanks* (child's name) have read and will abide by the agreement above and endeavor to support this program.
Date*
Name*

First NameLast Name
Signature*

Clear
If your student is in high school and is under the age of 16, do you give them permission to sign themselves in and out of program? (All participants in middle and elementary school must be signed in and out of program by an authorized adult)*

Yes, my student may sign themselves in and out of programNo, a guardian will sign the student in and out of programNot applicable- my child is in middle school or elementary school
Should be Empty:

Jasper's Corner Registration Form

Child Participant Information

Family Information

Family Contact Information

Emergency Contact Information

Medical Authorization

Child's Educational History

Waivers and Release Forms

Mandated Reporting

Image Consent and Release

University of Redlands Children's Program Agreement