Homework Helper Program Application (Child)

Homework Helper Application (Child)

Hosted by James Samaritan at 409 N Jefferson Ave. Covington, LA 70433
The HOMEWORK HELPER Program will take place on Tuesdays and Thursdays from 3:00pm (after school) to 5:30pm. We will follow the STPSB calendar and will not have tutoring on days when school is out.

Our tutors are background checked and trained specifically to work with children who have experienced loss, family seperation or trauma. In a safe and loving environment, children receive assistance with homework and participate in high interest activities, to meet their academic goals.

Our resource teacher will work directly with the child's caregiver and teachers to make a tutoring plan specific to the child's needs. Our HOMEWORK HELPER schedule allows students time to have a snack, unwind, hangout, draw, shoot baskets and socialize before diving in to the academic work. Tutors are supported by staff and help plan fun, engaging enrichment activities as rewards for acheiving academic goals.

For questions related to the HOMEWORK HELPER Program, please email melissa@jamessamaritan.org

HOMEWORK HELPER ACTIVITIES PERMISSION & RELEASE FORM
As the undersigned legal parent or caregiver, I request that my child be allowed to participate in the HOMEWORK HELPER Program.

This Activities Permission & Release Form is effective on the date of my signature below, and will remain in full force and effect as long as my child participates in any manner; it applies to all HOMEWORK HELPER activities, group meetings, functions, and events (the "Activities").

I hereby give permission for my child to attend and participate in the Activities. I specifically authorize James Samaritan staff to provide for, and arrange in my place, necessary medical care, as stated in the Medical release Form.

In consideration for permitting my child to attend and/or participate in the Activities, I do hereby release, and on behalf of my child release James Samaritan Inc. in connection with any of the Activities ("Released Parties") from any and all claims for injuries, losses, damages, costs and expenses that I, and/or my child, might have against the Released Parties, arising out of, or in any way relating to, my child and the Activities, and I agree to hold the Released Parties harmless from any loss arising from such claims.
NO CHILD WILL BE PERMITTED TO PARTICIPATE IN ANY HOMEWORK HELPER ACTIVITY UNLESS THIS FORM IS COMPLETED AND SIGNED FOR EACH CHILD.
Child's name *
Preferred Name*
Sex*

MaleFemale
Birth Date*

MonthDayYear
Date
T-Shirt Size*
chose one from drop down
Age *
School *
Teacher (homeroom)

First NameLast Name
Grade *
Describe why you would like to enroll this child in the HOMEWORK HELPER Program.
In which areas does this child need the most assistance?*
Child's current caseworker, therapist or school counselor *
First and Last Name
Caseworker, therapist or school counselor phone number*
phone number
Caregiver's name*

First NameLast Name
Relationship to Child*
Caregiver's name (if there's more than 1)

First NameLast Name
Relationship to Child
Home Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver's Email*
example@example.com
The child is living with: (Check one)*

Biological ParentRelativeFoster ParentAdoptive ParentGroup HomeOther
Other Adult Authorized to pick up
Name
Relationship to Child
Other contact's phone

Area CodePhone Number
Yes, I would like my child to be considered for the HOMEWORK HELPER program this year. Once enrolled, I will commit to getting my child to and from James Samaritan. I understand that consistent participation in the program is required to remain eligible for resources and incentives in the program. If I should, for any reason, decide that my child will not continue to participate, I will notify the director as soon as possible to allow another child to benefit from the program.

I am aware that the program closes at 5:30pm and that I must pick up my child or arrange for an authorized person to pick them up on time. Repeated late pickups will result in the loss of my child's spot in the program.
Name

First NameLast Name
HOMEWORK HELPER MEDICAL RELEASE FORM
Child's Name*

First NameLast Name
Family Physician or Clinic*
Phone Number*

Area CodePhone Number
My child is taking the following medications (prescription or otherwise):
My child has the following medical conditions:
My child has allergic reactions to the following:
This Medical Release Form is effective on the date of my signature(s) below, and will remain in full force and effect as long as my child participates with HOMEWORK HELPER Program in any manner; it applies to all HOMEWORK HELPER activities.

I hereby give permission for my child to attend and participate in the Activities. I specifically authorize James Samaritan to provide for, and arrange in my place, necessary medical care.
This Medical Release Form will be used only as necessary in the circumstances. Every reasonable effort will be made to first notify a caregiver listed below prior to the use of this Medical Release Form.
Caregiver's name*

First NameLast Name
Relationship to child:*
Signature*
MonthDayYear
Should be Empty:

Homework Helper Application (Child)

HOMEWORK HELPER ACTIVITIES PERMISSION & RELEASE FORM

HOMEWORK HELPER MEDICAL RELEASE FORM