Resilient Kids Enrollment Form

After School Program

When: Starting September 18th, Monday-Thursday, 2:45 PM - 5:00 PM

Where: The Rose Bowl, 7419 E 11th St, Tulsa, OK 74112

Who: K-5th Grade Students

Program Application
Date*

MonthDayYear
Date
Name of person completing this Registration Form*
Primary contact number?*
Only a parent or legal guardian can complete the registration form.
Are you the parent or legal guardian of this student?*

YesNo
Student Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
School*
Explain Schooling Situation if OTHER
Grade (2023-24)*
Age*
Ethnicity
Gender*
Does the student have any behavioral problems, learning disabilities, or any other diagnoses they have received from the school district?*
Does the student have an IEP?*

YesNo
What is the student interested in?*
What is the student especially good at?*
Has the student previously attended One Hope's Resilient Kids/getAHEAD program?*

YesNo
Student T-Shirt Size*
Student's Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Would you like to enroll another child?*

YesNo
Student 2 Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
School*
Explain Schooling Situation
Grade (2021-2022 school year)*
Ethnicity
Gender*
Does the student have an IEP?*

YesNo
Does the student have any behavioral problems, learning disabilities, or any other diagnoses they have received from the school district?*
What is the student interested in?*
What is the student especially good at?*
Has the student previously attended One Hope's Resilient Kids/getAHEAD program?*

YesNo
Student T-Shirt Size*
Would you like to enroll another child?*

YesNo
Student 3 Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
School*
Explain Schooling Situation
Grade (2021-2022 school year)*
Ethnicity
Gender*
Does the student have an IEP?*

YesNo
Does the student have any behavioral problems, learning disabilities, or any other diagnoses they have received from the school district?*
What is the student interested in?*
What is the student especially good at?*
Has the student previously attended One Hope's Resilient Kids/getAHEAD program?*

YesNo
Student T-Shirt Size*
Caregiver Information
Name (first and last)*
Street Address (if different from student's address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*
What phone number can we use to text you important information about Resilient Kids?*
E-mail *
Emergency Contact 1
Name*

First NameLast Name
Phone Number*
Emergency Contact 2
Full Name*

First NameLast Name
Primary Phone Number*
Transportation From School to Resilient Kids
Which pick-up location will your child be at?*
Late Pick-Up Policy

Students must be picked up from the Rose Bowl between 4:50-5:10 pm

We do not offer transportation after Resilient Kids.
1. ANY PARENT WHO WILL BE LATE MUST CALL.
2. We understand that unavoidable circumstances come up. Our goal is to support you and your child 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 4:30 p.m., the late fee will be assessed.
4. If a parent is late picking up their child 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 child will be suspended until the fees are paid.
5. If a parent is late picking up their child a third time, in addition to the fee being charged, we will set a meeting with the parent/guardian to discuss how we can move forward.
6. Late Fee Schedule:
  - 5:10-5:30 $10.00
  - 5:30-5:45 $25.00
Do you agree to the late policy?*

YesNo
Do you understand that absences from Resilient Kids can result in your student losing his/her place in the program?*

YesNo
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.*
Does the 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.

TylenolBenadrylIbuprofenTumsNeosporinCalamine lotionCough dropsInsulin shotEpi-penI 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 the 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 consentOther
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.Other
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.
Requested Pick-up location. Only fill out if you selected REQUEST OTHER LOCATION. *One Hope cannot guarantee that we will have enough drivers to pick your child up but we will consider and get back to you.
IF One Hope is transporting your child: I give permission for my child to be transported to and from Resilient Kids and to and from events, activities, and field trips associated with One Hope, formal or informal.

YesOther
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