Beyond The Classroom Application

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 NameLast Name
Student Date of Birth

MonthDayYear
Date
Student Gender
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Ethnicity

Other
Is this student their own guardian or will they become their own guardian when they turn 18?
Parent/Guardian #1 Name

First NameLast Name
Relationship to Student
Parent/Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Second Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 preferred communication method
Parent/Guardian #2 Name

First NameLast Name
Relationship to student

Other
Parent/Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Second Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 preferred way of communication.
Which Parent/guardian should staff contact first while the students are with SOAR.
Skills Classes
Which of the following courses has your student taken/is taking

Other
Select following life skill areas you would like your student to stengthen.

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.
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.
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:
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.
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.
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.
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 NameLast Name
Emergency Contact #1 Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Secondary Contact
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 Authorized To Pick Up
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Authorized To Pick Up
Medical Information
I authorize SOAR Staff to obtain emergency medical care including transportation for my child to a hospital or other medical facility.
Physician Name
Physician Phone
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cognitive Functioning: check all the apply

Other
If other, explain
Physical Conditions: check all that apply

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
Socialization
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
Should be Empty:

Beyond The Classroom Application

Skills Classes

Acknowledgement and Permissions

Non/Parent/Guardian Emergency Contacts

Medical Information

Signatures