CLC 20013 MARVEL*US COMPREHENSIVE ENROLLMENT FORM

Benefit Information
Please review carefully if your household has received any of the below-listed FCDJFS benefits in the last 30 days. Proof of benefits must be provided during the enrollment process.

FCDJFS - Franklin County Department of Job and Family Services
Has your household received any of these benefits in the last 30 days?*

Ohio Works First - Cash AssistanceSupplemental Nutrition Assistance Program (SNAP) - Food AssistanceNo, we have not received FCDJFS benefits
Proof of FCDJFS Benefits on file?

YesNo
Proof of FCDJFS Benefits

Please upload documentation of your FCDJFS benefits. If you are unable to upload the documents here, please send it to camp@columbusliteracy.org.
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Applicant Signature
1. I certify I am the parent or legal guardian of a minor child and the information provided on this application is complete and correct to the best of my knowledge.

2. I understand that the information on this form will be used to determine eligibility for a TANF Funded program.

I understand that receiving these services will not prevent me from receiving other PRC assistance offered by Franklin County.
TANF Application - Parent/Legal Guardian Signature*

Clear
Program

After School 25-26
Subrecipient
Site Location

Chantry Drive
Re-enrollment

No
Enrollment Staff

Faith SadlerAngelique ClayTanisha GainesChris BrunkOther

MARVEL*US Program Consent and Waiver
ROI Version

V 2024-05-14
CLC PARENT HANDBOOK

As part of the CLC MARVEL*US program, CLC distributes a Policies and Procedures Handbook. This handbook contains important information on how the program operates, staff policies, program and safety procedures, pick-up/drop-off, attendance policy, program outline, and schedule. I acknowledge that I have received the CLC MARVEL*US PARENT HANDBOOK and agree to abide by the Code of Conduct as outlined therein.

Click here to download the PARENT HANDBOOK
LIABILITY WAIVER AND RELEASE

1. Acknowledgement of Risk: I acknowledge that participation in the MARVEL*US program (hereinafter referred to as "the Camp"), which is organized and operated by the Columbus Literacy Council (CLC), involves inherent risks and hazards, including but not limited to physical activities, sports, crafts, and other camp-related activities. I understand that these activities may result in injuries, including but not limited to, sprains, strains, fractures, scrapes, bruises, and other physical injuries.

2. Assumption of Risk: I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, that may be sustained by me (or my child, if the participant is a minor) as a result of participating in the Camp.

3. Release of Liability: In consideration for being allowed to participate in the Camp, I hereby release, waive, discharge, and covenant not to sue the CLC, its directors, officers, employees, volunteers, and agents from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, that may be sustained by me (or my child, if the participant is a minor) or to any property belonging to me (or my child) while participating in the Camp.

4. Indemnification: I agree to indemnify and hold harmless the CLC, its directors, officers, employees, volunteers, and agents from any loss, liability, damage, or costs, including court costs and attorneys' fees, that they may incur due to my (or my child's) participation in the Camp, whether caused by the negligence of the CLC or otherwise.

5. Medical Treatment: In the event of an emergency, I authorize the CLC to arrange for medical treatment for me (or my child) and understand that I (or my insurance provider) will be responsible for the costs associated with any medical treatment. I also give permission for the attending physician(s) and other medical personnel to administer any necessary medical treatment in the event of an emergency.

6. Governing Law: This Release of Liability shall be governed by and construed in accordance with the laws of the State of Ohio.
MEDIA WAIVER AND RELEASE

As part of the CLC MARVEL*US program, CLC routinely uses media methods (photography, video, recordings) of participants and activities to promote our programs and the great work being accomplished. I understand that by participating in the program, I give CLC the right to use media in which my kids may appear and allow CLC to record all virtual sessions.

For valuable consideration received, I grant to Columbus Literacy Council the absolute and irrevocable right and unrestricted permission concerning any photographs and/or video that it takes or may take of me/my kid(s) or in which I/my kid(s) may be included with others, to use, reuse, publish, and republish the photographs and/or videos in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration; and to use my/my kid(s) name in connection with any use it so chooses. I release and discharge Photographers/Videographers from any and all claims and demands that may arise out of or in connection with the use of the photographs and/or videos, including without limitation any and all claims for libel or violation of any right of publicity or privacy. I am a legally competent adult and have the right to contract in my own name or in the name of my minor child. I have read this document and fully understand its contents. This release shall be binding upon me and my heirs, legal representatives, and assigns.
Participant Name*
Parent/Legal Guardian Name*
I have received and read the CLC Parent Handbook, this Liability Waiver and Release as well as this Media Waiver and Release in its entirety and fully understand its terms. I understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing this agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.*

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PG-13 Movie Release
Throughout the program, there will be opportunities for the students to watch a movie.

Many of these movies are now mostly PG-13 (in our example Marvel movies). The movies will be used to enhance our curriculum or tie an educational concept to something our students can relate to (such as fiction or nonfiction writing, examples of genres, book versus movie content, development of the character, building our own superhero, etc).

Please indicate below if your child may participate in these class activities. If there are any specific PG movies that you do not want your child to watch, please list them in the appropriate section of this form. Should you have any questions or concerns, you may contact MARVEL*US Staff.
Participant Name*
Parent/Legal Guardian Name*
Please choose if you permit your child to watch PG-13 movies.*

I give my permission for my child to watch PG-13 movies. I understand that movies will be used to enhance the curriculum being taught.I DO NOT give my permission for my child to participate in any PG-13 movies that may be shown.
Please list any specific PG-13 movies that you do not want your child to watch.
Movie Release - Parent/Legal Guardian Signature*

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Emergency Medical Authorization
PURPOSE: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under CLC authority, when parents or guardians cannot be reached.
Participant Name*
Parent/Legal Guardian Name*
I hereby consent for the following medical care providers and local hospitals to be called:
In an emergency situation, you have permission to seek treatment from:*

The local children's hospital or appropriate hospital staff.The medical care providers I listed.
Preferred Hospital*
Hospital Phone Number*
Please enter a valid phone number.
Physician*
Physician Phone Number*
Please enter a valid phone number.
Dentist*
Dentist Phone Number*
Please enter a valid phone number.
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and, (2) the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Please list any facts concerning your child's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted.*
If not applicable, please enter N/A.
Does your child need any medications during the day at camp?*

YesNo
Please list any medications your child will need during the day at camp, including dosage, time and with or without food.*
If not applicable, please enter N/A.
Please complete the Request for Administration of Medication form on the next page.
Emergency Medical - Parent/Legal Guardian Signature*

Clear

Request for Administration of Medication

No medication will be given until this form is completed and required documentation is provided.
Participant Name*
Parent/Legal Guardian Name*
Prescription Medication
- Medication must be in its original container with the child's name and dosage instructions.
Over-the-Counter Medication
- A written note specifically for the child from the physician's office detailing the medicine, duration, dose, and timing is required.
How many medications will your child need to take at camp?*
First Medication
1 | Medication Name*
1 | Type of Medication*

PrescriptionOver-the-Counter
1 | Dosage*
1 | Time of Administration*

Hour Minutes

AM/PM Option
1 | Duration*
1 | Instructions*
Second Medication
2 | Medication Name*
2 | Type of Medication*

PrescriptionOver-the-Counter
2 | Dosage*
2 | Time of Administration*

Hour Minutes

AM/PM Option
2 | Duration*
2 | Instructions*
Third Medication
3 | Medication Name*
3 | Type of Medication*

PrescriptionOver-the-Counter
3 | Dosage*
3 | Time of Administration*

Hour Minutes

AM/PM Option
3 | Duration*
3 | Instructions*
Additional Comments
Medical Documentation

Please upload a written note specifically for the child from the physician’s office detailing the medicine, duration, dose, and timing for any over-the-counter medication. If you are unable to upload the document here, please send it to camp@columbusliteracy.org.
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I hereby request and authorize the MARVEL*US staff to administer the medication(s) as prescribed above to my child. I understand that it is my responsibility to provide the medication in its original container, labeled with my child’s name and the prescribed dosage. I also understand that over-the-counter medications will require a physician's written instructions and cannot be administered without this documentation. I release the camp and its staff from any liability or claims arising from the administration of the medication(s) as authorized in this form.*

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Operation Agreement
The current operation agreement is included in the parent handbook. Please visit the parent handbook for details.
Operation Agreement Version*

After School 2024/1
Participant Name*
Parent/Legal Guardian Name*
My signature is acknowledgement that I read and voluntarily consented to the MARVEL*US Operation Agreement and am aware of the camp hours, including drop off and pickup times and fees for late pickup.*

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Behavior Expectations and Disciplinary Procedures
The behavior expectations and disciplinary procedures are included in the parent handbook. Please visit the parent handbook for details.
Disciplinary Version*

After School 2024/1
Participant Name*
Parent/Legal Guardian Name*
My signature is acknowledgement that I read and voluntarily consented to the MARVEL*US Behavior Expectations and Disciplinary Procedures.*

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Should be Empty:

Enrollment Form

Participant Information

Parent/Legal Guardian Information

Benefit Information

Income Information

Zero Income Statement

Household Members

Ineligible Household Members

Applicant Signature

MARVEL*US Program Consent and Waiver

PG-13 Movie Release

Emergency Medical Authorization

Request for Administration of Medication

First Medication

Second Medication

Third Medication

Operation Agreement

Behavior Expectations and Disciplinary Procedures