Child Enrollment Form (2024-2025)

1
Did your child participate in ELEVATE during the 2023-2024 school year or summer 2024?* This field is required.
YESNO
2
Child's Name* This field is required.
First Name
Last Name
3
Does your child have a preferred name/nickname?* This field is required.
YESNO
4
Preferred Name or Nickname* This field is required.
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Gender* This field is required.
Male
Female
Non-binary
Prefer not to answer
7
Please select the child’s race/ethnicity.* This field is required.
Arabic
Asian or Pacific Islander
Black or African-American
Hispanic or Latino
Native American or Alaskan Native
Middle Eastern
Multiracial or Biracial
White or Caucasian
A Race/Ethnicity Not Listed Here
8
Please specify the child’s race/ethnicity. * This field is required.
9
Has the primary language spoken at home changed since last school year?* This field is required.
YESNO
10
What is the primary language spoken at home?* This field is required.
English
Arabic
Other
11
Please indicate the primary language spoken at home.* This field is required.
12
What size t-shirt does your child wear?* This field is required.
Youth small
Youth medium
Youth Large
Adult small
Adult medium
Adult large
Adult XL
13
Have the topics or information you would like more information about changed since last school year?* This field is required.
YESNO
14
Please tell us what types of topics or information you would like more information about.* This field is required.Select all that apply
Resources/information to help my child do better in reading
Resources/information to help my child do better in math
Increasing my child's self-esteem
Increasing my child's confidence
Helping my child get along better with other children
Stress management
Easy meals/recipes to prepare for my family
How to find my child's talent
How to challenge my child without overwhelming her/him
New trends affecting my child's safety
Other
15
Please indicate the specific topic/information you would like more information about. * This field is required.
16
Have the kinds of activities you want to participate in changed since last school year?* This field is required.
YESNO
17
Please tell us what kinds of activities you would like to participate in.* This field is required.Select all that apply
Cooking classes
Crafts
Planning events for the holidays
Health and wellness activities
Attending out of town conferences for parents
Visiting cultural learning places
Other
18
Please indicate the specific activity you would like information on. * This field is required.
19
Has your preferred method of communication with Center of Hope and other parents changed since last school year?* This field is required.
YESNO
20
How would you like to communicate with Center of Hope and other parents:* This field is required.Select all that apply
In-person meetings
Zoom meetings
Send me flyers or paper handouts
Text me the information and I'll ask if I have questions
Provide a question box for me to put my questions in
21
Have any of the barriers you reported changed since last school year?* This field is required.
YESNO
22
At Center of Hope, we seek to be responsive to our clients. We actively look for ways to connect you with resources that make life easier and more satisfying. Please indicate if you would like support with any of the barriers listed below:
Food
Transportation
Unemployment
Child Support/Custody
Parenting Support Group
Health
Education
Hearing Support/Attorney Referrals
CSEA/LCJC paperwork help
Support at child's school
Questions about child's school or progress at school
23
Do you have any other goals you'd like Center of Hope to help you meet?
Employment
High School Diploma or GED
College Enrollment
Strategies for communicating with my child's teacher(s)/principal
Strategies for having difficult conversations with my children
A better understanding of my child's school system
A better understanding of how the Lucas County Juvenile Court System works
A better understanding of how Children's Services works
Child support adjustments
Mental health and wellness
Physical health care
Dental health care
Driver's license reinstatement
Cooking class participation
24
2024-2025 Grade level?* This field is required.
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
25
Please select your child's school* This field is required.
Hillview
Old West End
Silvercreek
Sylvan
Whiteford
Other
Stranahan
Toledo Islamic Academy
Holloway
Holland Intermediate
Other
26
Please list the school* This field is required.
27
Has your child ever repeated a grade?* This field is required.
Yes
No
28
Your Name* This field is required.
First Name
Last Name
29
Has your address changed since last school year? * This field is required.
YESNO
30
Your Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
31
Your relationship to the child* This field is required.
Mother
Father
Aunt
Uncle
Stepfather
Grandmother
Grandfather
Cousin
Brother
Sister
Family Friend
32
Has your phone number changed since last school year?* This field is required.
YESNO
33
How can you be reached by phone?* This field is required.
Mobile phone
Home phone
Work phone
34
Home Phone* This field is required.
Area Code
Phone Number
35
Work Phone* This field is required.
Area Code
Phone Number
36
Cell Phone* This field is required.
Area Code
Phone Number
37
Has your email address changed since last school year?* This field is required.
YESNO
38
Email Address* This field is required.
example@example.com
39
Parent/Guardian's Name* This field is required.
First Name
Last Name
40
Parent/Guardian’s relationship to the child* This field is required.
Mother
Father
Aunt
Uncle
Stepfather
Grandmother
Grandfather
41
Does the child live with this parent or guardian?* This field is required.
YESNO
42
Does the child have additional parents/guardians?* This field is required.
YESNO
43
Parent/Guardian's Name* This field is required.
First Name
Last Name
44
Parent/Guardian’s relationship to the child* This field is required.
Mother
Father
Aunt
Uncle
Stepfather
Grandmother
Grandfather
45
Is Parent/Guardian 2’s address the same as Parent/Guardian 1’s?
YESNO
46
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
47
Home Phone* This field is required.
Area Code
Phone Number
48
Work Phone* This field is required.
Area Code
Phone Number
49
Cell Phone* This field is required.
Area Code
Phone Number
50
Email* This field is required.
example@example.com
51
Does the child live with this parent or guardian?* This field is required.
Yes
No
52
Has the emergency contact for your child changed since last school year? * This field is required.
YESNO
53
Name* This field is required.
First Name
Last Name
54
Relationship to Child* This field is required.
55
Relationship to the Child* This field is required.
Mother
Father
Grandmother
Grandfather
Brother
Sister
Cousin
Family Friend
Aunt
Uncle
56
How can you be reached by phone?* This field is required.
Mobile phone
Home phone
Work phone
57
Home Phone* This field is required.
Area Code
Phone Number
58
Work Phone* This field is required.
Area Code
Phone Number
59
Cell Phone* This field is required.
Area Code
Phone Number
60
Do you have additional emergency contacts for your child?
YESNO
61
Name
First Name
Last Name
62
Relationship to Child
63
Relationship to the Child* This field is required.
Mother
Father
Grandmother
Grandfather
Brother
Sister
Cousin
Family Friend
Aunt
Uncle
64
How can they be reached by phone?* This field is required.
Mobile phone
Home phone
Work phone
65
Home Phone
Area Code
Phone Number
66
Work Phone
Area Code
Phone Number
67
Cell Phone
Area Code
Phone Number
68
Do you have additional emergency contacts for your child?
YESNO
69
Name
First Name
Last Name
70
Relationship to Child
71
Relationship to the Child* This field is required.
Mother
Father
Grandmother
Grandfather
Brother
Sister
Cousin
Family Friend
Aunt
Uncle
72
How can they be reached by phone?* This field is required.
Mobile phone
Home phone
Work phone
73
Home Phone
Area Code
Phone Number
74
Work Phone
Area Code
Phone Number
75
Cell Phone
Area Code
Phone Number
76
Has a doctor or health professional ever told you that this child has any of the following conditions?* This field is required.
Asthma
Hearing Problems
Vision Problems
Attention Deficit Disorder or Attention Deficit Hyperactive Disorder, that is ADD or ADHD
Depression or anxiety problems
Behavior or conduct problems
Bone, joint, or muscle problems
Diabetes
Autism
Any developmental delay or physical impairment
None
77
During the past 12 months, have you been told by a doctor or other health professional that this child had any of the following conditions?* This field is required.
Hay fever or any kind of respiratory allergy
Any kind of food or digestive allergy
Eczema or any kind of skin allergy
Frequent or severe headaches, including migraines
Stuttering, stammering, or other speech problems
Three or more ear infections
None
78
Does your child have any known allergies?* This field is required.
YESNO
79
Please list their known allergies:* This field is required.
80
Does this child currently need or use medicine prescribed by a doctor?* This field is required.
Yes
No
81
Please list the medication(s):
82
Is this child limited or prevented in any way in his/her ability to do the things most children of the same age can do?* This field is required.
Yes
No
83
Please explain how this child is limited or prevented in any way in his/her ability to do the things most children of the same age can do:
84
Has a doctor, health professional, teacher, or school official ever told you that this child has a learning disability?* This field is required.
Yes
No
85
Please explain what the doctor, health professional, teacher, or school official said about this child’s learning disability:
86
Has this child been to the doctor for any reason in the last 12 months?* This field is required.
Yes
No
87
Has this child been to the dentist in the last 12 months?* This field is required.
Yes
No
88
Please explain any special procedures that should be followed in the event of a medical emergency:
89
How did you hear about this program?* This field is required.
90
What other enrichment or extra-curricular activities does your child participate during the year (for example, organized sports, music or dance lessons, academic tutoring, clubs or organizations)?
91
Students attending the schools below get transportation. Please select your child's school from the list. If your child's school isn't listed below, we do not provide transportation to/from it at this time.* This field is required.
Hillview
Old West End
Silvercreek
Sylvan
Whiteford
My child's school isn't listed here
Stranahan
Holloway
Holland Intermediate
Toledo Islamic Academy
Arbor Hills
St. Patrick’s
92
I Parent/Guardian First Name *     Parent/Guardian Last Name * give    Student First Name *     Student Last Name * permission to ride the Toledo Public School Bus to Center of Hope Family Services (4447 Talmadge, Suite G) at the end of the school day. I agree to pick my child from the ELEVATE Program at Center of Hope Family Services each day no later than 6:30 PM.

My child will participate in ELEVATE at Center of Hope Family Services, and will catch the bus at their school on the following days (select each day that you want service):

Monday     Tuesday     Wednesday     Thursday        Friday *

     Signature *
Date *
93
I Parent/Guardian First Name *     Parent/Guardian Last Name * give    Student First Name *     Student Last Name * permission to ride the Black and White Transportation to Center of Hope Family Services (4447 Talmadge, Suite G) at the end of the school day. I agree to pick my child from ELEVATE Program at Center of Hope Family Services each day no later than 6:30 PM.

Monday     Tuesday     Wednesday     Thursday        Friday *

     Signature *
Date *
94
I Parent/Guardian First Name *     Parent/Guardian Last Name * give    Student First Name *     Student Last Name * permission to ride the Washington Local School Bus to Center of Hope Family Services (4447 Talmadge, Suite H) at the end of the school day. I agree to pick my child from the ELEVATE Program at Center of Hope Family Services each day no later than 6:30 PM.

Monday     Tuesday     Wednesday     Thursday        Friday *

     Signature *
Date *
95
Unfortunately, we don't offer transpoartation to/from your child's school at this time.
96
Your child is invited to participate in the ELEVATE after school program evaluation. The evaluation is being funded by a federal 21st CCLC grant awarded by the Ohio Department of Education. It is being conducted by Measurement Resources Company based in Columbus, Ohio. Data Collected may include: grade, gender, race, ELL status, special needs status, Free/Reduced (Income) Eligibility, disciplinary data, school day attendance, grades, test scores, Lucas County Residence, and family demographics. There may be times that we need to collect additional paperwork as required by the Ohio Department of Education and other funders. The information collected will help us to measure the effects of our services for children, parents and families at your school; and to develop, improve, and sustain our programming. If you do not want your child to participate in the evaluation please check the box below and return this form to your ELEVATE staff before the first day of programming. If you have any questions about this evaluation, feel free to contact: Dr. Tracee Perryman (419) 861-4400* This field is required.
YES, I would like my child to participate in the evaluation.
NO, I do not wish my child to participate in the evaluation.
97
I hereby authorize and irrevocably grant to the Center of Hope Family Services Inc. and its affiliates, licensees, agents and assigns, the unrestricted right to use and publish any part of the information that I have given to Center of Hope Family Services and the right to record my name, voice, appearance, likeness, and comments on film, videotape, audiotape, still photographs, print, and any other media now known or hereafter invented. I acknowledge that Center of Hope Family Services shall own all right, title and interest in and to this media. I further agree that Center of Hope Family Services may cause all or parts of this media to be used for any and all publications, exhibitions, public displays, editorials, advertising or other purposes.* This field is required.
YESNO
98
Center of Hope Family Services has my permission to secure emergency transportation for my child in the event of an illness or injury that requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. I also give Center of Hope Family Services consent to request emergency treatment for my child if needed.* This field is required.
YESNO
99
I would like Center of Hope to connect me with resources and information that will support my child’s success in school. * This field is required.
YESNO
100
As a part of participating in the ELEVATE Program, I understand and agree to abide by the following guidelines:

1. My child must attend at a minimum, 2 days/week
2. My child must participate in all of the activities in the ELEVATE Daily Schedule
3. My child is expected to attend for the duration of the daily schedule
4. My child is expected to abide by the ELEVATE Citizenship Standards
5. My child is expected to complete iReady diagnostics, and weekly lessons

I also understand and support ELEVATE’s 4Rs classroom management policies:
1. Redirect – tell the child what they should be doing rather than restating what not to do.
2. Remind - remind the child of the appropriate behavior.
3. Reflection Island – place the child in reflection island to take a break from the group, think about the appropriate behavior and how he/she will return to the group demonstrating the appropriate behavior. 1 minute per year of age.
4. Return to the group – after identifying the appropriate behavior and agreeing to return to the group demonstrating the appropriate behavior.

I understand and accept ELEVATE’s exclusionary policies for the following behaviors listed below:
1. Disruptions – when a child persistently disrupts classroom learning.
2. Destruction of Property – when the child defaces, destroys, or damages property owned by CHFS, the school/site, a staff member, themselves, or another child.
3. Defiance – refusal to follow instructions or participate in ELEVATE activities. Refusal to respect adults, authority figures, or peers.
4. Direct Threat to Safety – when a child threatens physical and emotional safety to self, students and/or adults.
5. Failure to Follow the ELEVATE Attendance Policy – failing to attend at least 2 days per week; consistently leaving early
6. Failure to Make Progress - Failure to complete iReady assessments and weekly assignments; failure to meet expectations as outlined in enrichment activities.

I understand that CHFS managers retain sole discretion at all times to admit, exclude, suspend, or deny participation in the ELEVATE program to any child.
101
I agree to the guidelines on the previous page. * This field is required.
YESNO
102
I hereby certify that the statements in this application are correct and true. I understand that my child(ren)’s enrollment as a Center of Hope Family Services student is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by Center of Hope Family Services.* This field is required.
YESNO
Should be Empty: