STEAMS Application

STEAMS APPLICATION & CONSENT FORM

Smoketown Teen Empowerment and Mentoring Support (STEAMS), is a dynamic initiative dedicated to empowering the teens of Meyzeek Middle School in the vibrant Smoketown area.
Student Information
Student Name:

First NameMiddle NameLast Name
Student Birth Date

MonthDayYear
Student Gender at Birth:
Student Race:
Student Grade Level
Parent/ Guardian Information
Parent Name

First NameLast Name
Phone Number:

Area CodePhone Number
E-mail Address:
Your Email Address
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Alternate Emergency Contact Name:

First NameLast Name
Alternate Emergency Number

Area CodePhone Number
Household
Household Income:
Does your child qualify for free or reduced lunch?
Does your child have an IEP or other special needs?
Does your child have any emergency health needs or allergies (food, medication, environmental, etc.) or require any medications?
If yes, please describe your child's health needs and necessary precautions. Provide medication names, dosage, frequency and any special considerations.
Participant's Health Insurance Provider:
Participant's Health Insurance Policy Number:
Is there any other information about your child that you believe would be helpful for program staff to know?
RELEASES
CODE OF CONDUCT:I understand that my child is expected to adhere to the program's code of conduct, which includes respectful and responsible behavior. Any violation of the code of conduct may result in the participant being removed from the program.
MEDICATION/ EMERGENCY MEDICAL TREATMENT RELEASE: If my child requires medication during the program, I will provide detailed instructions to the program staff, including dosage, frequency, and any special considerations. In the event that I, or the emergency contact listed, cannot be reached in the case of a medical emergency, I authorize the program staff to seek medical treatment for my child.
MEDIA RELEASE: Photos/ Videos are taken of the program throughout the year and may include your child directly or indirectly. These photos/ videos may be published through our website, social media, news bulletins, advertising and other media. Please indicate your consent and release of your child's image/ likeness to be used without notice and additional permission.
RECORDS RELEASE:I agree to allow the Smoketown T.E.A.M.S Program to collect grades, test scores, attendance discipline referrals, demographics and teacher surveys regarding my child's performance. I understand that all records and information regarding services are protected by confidentiality regulations governing the exchange of such information. The following agencies: Jefferson County Public School (JCPS) have my written consent to share information of a confidential nature among themselves in written or verbal form about my child.
PARTICIPATION RELEASE: As the parent/guardian, I hereby give consent for my child, to participate in the Smoketown T.E.A.M.S Mentorship Program organized by YouthBuild Louisville and Meyzeek Middle School. I understand that the program will take place at Meyzeek Middle School and the YouthBuild Community Center and may include planned field trips for participants. Assumption of Risk and Release of Liability: I acknowledge that participation in the program involves inherent risks, including, but not limited to, physical injury and exposure to new environments. I release STEAMS/ BLUEPRINT502, its staff, and volunteers from any liability arising from my child's participation.
Parent/ Guardian Initials:
Date

MonthDayYear
Date
Should be Empty:

STEAMS APPLICATION & CONSENT FORM

Student Information

Parent/ Guardian Information

RELEASES