Under 18 High School Enrollment

High School enrollment - under 18

This form is be filled out by a parent's or guardians of clients under the age of 18.
Welcome to ELC Haverhill! We're glad you're here. We hope to help challenge, encourage and empower your child/minor to grow in self-leadership and positively impact others. We are here to support them and look forward to working with you to help them become a culture curator.
Client Info
Client's full name:*

First NameLast Name
Client's Phone Number:
Please enter a valid phone number.
Client's Age:*
Client's Grade:*
Client's current school:*
What days does your child/minor plan to attend*

TuesdaysWednesdaysThursdays

Parent / Guardian Info
Parent / Guardian Name:*

First NameLast Name
Parent / Guardian Phone Number:*
Please enter a valid phone number.
Able to send and receive text messages?*
Parent / Guardian Email:
example@example.com
I commit to being available to center staff as needed in support of my child/ minor*
After the program client’s will be released. Clients are responsible to follow their dismissal plan as directed by their parent /guardian. If your client is unable to follow their dismissal plan or needs assistance it is their responsibility to notify center staff. After dismissal your client will be dismissed to:*

Public TransportationWalkerPick-up

Program Consent
1. The undersigned on their own behalf and on behalf of such children / minors, hereby releases, waives, discharges and covenants not to sue The Emerging Life Youth Center (ELYC) and or any branches of the Emerging Life Centers (ELC) branches thereof, its directors, officers, employees, and agents (hereinafter referred to as "releases") from all liability to the undersigned or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence of the releasees or otherwise while the undersigned or such children is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with The ELYC, ELC

2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any, loss, liability, damage or cost they may, incur due to the presence of the undersigned or such children in, upon or about The ELYC, ELC premises or in any way observing or using any facilities or equipment of The ELYC, ELC or participating in any program affiliated with The ELYC, ELC whether caused by the negligence of the releases or otherwise.

3. 'THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releasees or otherwise while in, about or upon the premises of The ELYC, ELC and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with The ELYC, ELC. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT and further agrees that no oral representations, statements, or inducement apart from the foregoing written agreement have been made.

4. The client and or client's parent/guardian understand that inner-wellness support services are offered as a part of the program and consent to participation. Inner-wellness specialists are available to offer emotional, spiritual and mental health support to clients and encourage positive decision making. Inner-wellness specialist, ELC staff nor any part of the ELC/ELYC program(s) do not replace nor is intended to substitute or provide professional mental health services.

5. Inner-wellness specialist and or ELC center staff may offer guidance in navigating emotional turbulence, addressing specific situational concerns, improving coping skills, or resolving interpersonal conflicts. Client information may be shared with staff, parents (if client is a minor) and disclosed if the clients safety or wellness is presumed at risk. Crisis intervention or EMS may be involved if a client is becoming unstable, poses a potential threat to themselves or others, or at the discretion of the inner wellness specialist/ ELC staff. If the client is a minor a parent or guardian will also be contacted.

6. The client and or client's parent/guardian understand and acknowledge that the inner-wellness specialist, ELC staff and any part of the ELC/ELYC program(s) cannot be held responsible or liable for any outcomes or consequences resulting from the information or support provided.
Iparent / guardian first and last name* give consent for my child / minor
Client's first and last name* to participate in the Emerging Life Youth Center/ ELC Haverhill program. I have read, understood and agree to the included consents.
Date*

MonthDayYear
Date
Parent / Guardian Signature*

Powered by Jotform SignClear

Client Agreement and Parent Involvement

Client conduct and parent involvement expectations
To clients: Welcome to the ELC Haverhill! We’re happy you’re here.

The ELYC/ ELC programs are designed with you in mind. We want you to know that you are valued, worthy, respected, and welcome. Our center is a place where you can learn and grow in a brave space environment with the support of your community and peers. To create/maintain this space for all, it is important that all clients treat staff, their peers, community leaders, and others; as valued, worthy, welcomed, and respected.

To create/maintain a safe brave space welcoming environment clients are expected to have the following standards for themselves:

As a client I will not use foul or derogatory language, I will not use threats, aggressive behavior, or engage in violence. I will not bring or distribute weapons, cognitive altering substances (both legal and or illegal), or explicit graphic content into the center or on center grounds. I will not participate in gang related activities while at or in connection to the center.

I commit to having a personal expectation of myself to take direction from center staff and leadership and comply with redirection requests, including removing myself from a space or situation in which conflict is becoming escalated. I agree to follow center policy and direction for conflict resolution and will bring to center staff/leadership’s attention if I feel unsafe, or unstable or become aware of others who may be unsafe or not in keeping with this commitment.

I understand that my enrollment and or participation in ELYC /ELC programs, activities, and use of facilities and equipment may be restricted or deferred up to and including indefinitely if I do not display a commitment to my confirmation or endanger the safety or well-being of others.

This confirmation is a statement of my understanding of the ELYC/ ELC commitment to providing a safe space for myself and others and my agreement to uphold that standard as my own.
CLIENT NAME PRINTED:First and last name
Date*

MonthDayYear
Date

Parent / Guardian Agreement
As a parent/ guardian of a center client your partnership is important to client success. Your support and respect of center staff sets an example for you client/ minor and helps encourage their maturity.

As a parent/ guardian of a center client, when interacting with center staff/ leadership and while at the center/ on center grounds:

I will not use foul or derogatory language, I will not use threats, aggressive behavior or engage in violence. I will not bring or distribute weapons, cognitive altering substances (both legal and or illegal) or explicit graphic content into the center or on center grounds.

I commit to have a personal expectation of myself to support my child/minor in decision making that enables positive peaceful outcomes. To encourage my child/ client to take direction from center staff and leadership, comply with redirection requests, including removing themselves /myself from a space or situation in which conflict is becoming escalated. I agree to follow center policy and direction for conflict resolution and will bring to center staff/leadership’s attention if I feel my child/minor is unsafe, unstable, if I and or my child/minor has a conflict or concern, or become aware of others who may be unsafe or not in keeping with this commitment.

I understand that my child/minors enrollment and or participation in ELYC /ELC programs, activities and use of facilities and equipment may be restricted or deferred up to and including indefinitely if they do not display a commitment to their confirmation or endanger the safety or wellbeing of others.

As a parent or guardian of a center client I understand that if I am not in keeping with my commitment to set an example for my client/minor’s decision making that enables positive peaceful outcomes when at the center and or interacting with center staff/leadership, my child/ minor’s participation in the center and or my presence at the center may be affected or restricted.

This confirmation is a statement of my understanding of the ELYC/ ELC commitment to providing a safe, brave space for myself, my child/minor and others, and my agreement to uphold that standard as my own.
PARENT / GUARDIAN NAME:parent / guardian first and last name
Date*

MonthDayYear
Date

Photos and Media
Photo / Video Consent*

I give permission of my child’s image to be used in photo/media and social media post and advertisements in publicity and fundraising mediaI do not give permission for my child’s image to be used in photo/media and social media posts and advertisements in publicity and fundraising media. My child/minor understands it is their responsibility to remove themselves from photo/media opportunities.
CLIENT NAME PRINTED:client photo printed
PARENT / GUARDIAN NAME PRINTED:photo signature

Medical
I Parent / Guardian ofClient Name* give consent for my child / minor to receive first aid and or be transported and receive medical care in the event of an emergency
Your child /minor should be aware of their restrictions and avoid foods or situations that may cause them to experience an adverse reaction. To keep your child /minor safe they should be aware of and carry any emergency medications they may need and be able to independently administer them appropriately as needed.
My child / minor requires emergency medications*

Yes, my child / minor requires the following emergency medications that have been prescribed by their health care provider. I attest that my child / minor is aware of the proper use and indication of their medication and they are able to administer their medication independently as needed. In the event my child feels they need to use their medication and or is experiencing an emergency they will notify center staff immediately.no
Please list them here:
PARENT / GUARDIAN NAME PRINTED:First and last name
Should be Empty:

High School enrollment - under 18

Welcome to ELC Haverhill! We're glad you're here. We hope to help challenge, encourage and empower your child/minor to grow in self-leadership and positively impact others. We are here to support them and look forward to working with you to help them become a culture curator.

Client Info

Parent / Guardian Info

Household Info

Program Consent

Client Agreement and Parent Involvement

Parent / Guardian Agreement

Photos and Media

Medical