Beyond The Classroom Application
SOAR Fox Cities: 211 E Franklin St., Appleton, WI 54911
Beyond The Classroom is a partnership with Appleton Area School District to build upon life skills and community engagement for students identified by the school district.
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Answer
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Ethnicity
*
African American/Black
White / Caucasian
Native American
Alaskan Native
Asian/Pacific Islander
Hispanic
Unspecified
Other
Is this student their own guardian or will they become their own guardian when they turn 18?
Yes
No
Parent/Guardian #1 Name
*
First Name
Last Name
Relationship to Student
*
Mother
Father
Grandparent
Guardian
Other
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #1 Mobile Phone Number
*
Please enter a valid phone number.
Parent/Guardian #1 Second Phone Number
Please enter a valid phone number.
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 preferred communication method
*
Email
Phone
Text
Parent/Guardian #2 Name
First Name
Last Name
Relationship to student
Mother
Father
Grandparent
Guardian
Other
Parent/Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Mobile Number
Please enter a valid phone number.
Parent/Guardian #2 Second Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 preferred way of communication.
Email
Phone
Text
Which Parent/guardian should staff contact first while the students are with SOAR.
*
Please Select
Parent/Guardian #1
Parent/Guardian #2
Skills Classes
Which of the following courses has your student taken/is taking
PAES Lab
Cooking
Life Skills Training
Community Work Experience
Other
Select following life skill areas you would like your student to stengthen.
Cooking/Kitchen Safety
Transportation/Public Safety
Social Emotional Awareness
Leisure/Recreational Skills
Community Engagement
Financial Literacy
Other
List the Student's Interests and/or Activities they Enjoy
Acknowledgement and Permissions
Available upon request.
Hold harmless agreement: I indemnify and hold harmless SOAR Fox Cities, and of its employees and/or agents from all claims from my use of SOAR property or participation in any programs. I will further indemnify and hold harmless SOAR Fox Cities, its employees and/or agents from all costs, expenses and liabilities resulting from any claim brought from my child(ren)’s use of SOAR property and/or participation in SOAR programs to the extent of SOAR's liability under general law.
*
Yes
No
Admission: Parents have a duty to share significant medical, physical or behavioral needs at time of application. Should there be a significant behavior situation, SOAR staff reserve the right to have a student return home. Due to group format, Beyond The Classroom is unable to provide one-on-one care. Beyond The Classroom will provide a maximum of 1:3 ratio.
*
Agree
Disagre
Some elements of Beyond the Classroom programming will take students into the community for experiential learning opportunities. This will require walking and/or using other means of transportation to include public transportation. I give permission for my child to participate in the following activities:
*
I give permission for my child to participate in off site activities.
I do not give permission for my child to participate in off site activities.
Image Authorization: I authorize SOAR Fox Cities to use any photographs or videos taken of my child for promotional reasons including website, social media, brochures, flyers or newsletter.
*
Yes
No
Cancelation Policy: If student will be missing school as a result of a planned absence, please let SOAR staff know as well so we can plan activities appropriately.
*
Agree
Disagree
I understand that ONLY persons on the “Authorized Person(s)” list will be allowed to pick up my child and that they and I will be required to present photo identification until staff recognize parent/guardian/emergency contact, before my child is released. Should someone else need to pick up my child, parent/guardian must provide written notification. This person will need to show photo identification to pick up as well.
*
Agree
Disagree
Non/Parent/Guardian Emergency Contacts
The following Individuals are authorized to help when parents can not be reached including emergency situations.
Emergency Contact #1 Name
*
First Name
Last Name
Emergency Contact #1 Primary Phone
*
Please enter a valid phone number.
Emergency Contact #1 Secondary Contact
Please enter a valid phone number.
Emergency Contact #1 Authorized To Pick Up
*
Yes
No
Emergency Contact #2 Name
*
First Name
Last Name
Emergency Contact #2 Primary Phone
*
Please enter a valid phone number.
Emergency Contact #2 Secondary Phone
Please enter a valid phone number.
Emergency Contact #2 Authorized To Pick Up
*
Yes
No
Medical Information
I authorize SOAR Staff to obtain emergency medical care including transportation for my child to a hospital or other medical facility.
*
Yes
No
Physician Name
*
Physician Phone
*
Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cognitive Functioning: check all the apply
*
Cognitive Disability level Mild
Cognitive Functioning Moderate
Attention Deficit Disorder
Mental Health Issues
Down Syndrome
Autism
Other
If other, explain
Physical Conditions: check all that apply
*
Spinal Cord Injury
Visual Impairments
Cerebral Palsy
Stroke
Heart Condition
Epilepsy/Seizure
Asthma
Other
If yes to Epilepsy, please give details of type, frequency, date of last seizure and treatment
If other, explain
Specify Food Allergies: if none, write NKA (no known allergies)
*
Specify Non-Food Allergies: if none, write NKA (no known allergies)
*
Eating
Difficulty Chewing
Choking risk
Stuffs Mouth
Portion Control
Socialization
*
Social
Complaint
Helpful
Cautious
Wanders/Elpoes
Self Abusive
Withdrawn/Shy
Clings to Opposite sex
Verbally Aggressive
Physically Aggressive
Other
Explain: Give as much detail as possible, this is very helpful to staff. Please share any behavior plans you use at home as well.
Triggers: Please list any triggers for behaviors.
Signatures
*
Registration Date
*
Continue
Continue
Should be Empty: