PROPEL 2026-2027 Student Application

PROPEL YOUR FUTURE

1600 NW 15th Vista Boca Raton, FL 33432

561-955-8553 WWW.PROPELYOURFUTURE.ORG

Fall 2026 - Spring 2027

Filling out this form does not guarantee acceptance into the program. PROPEL will hold interviews at the beginning of the Fall, Spring, and Summer terms. Space is limited.

ANY QUESTIONS - PLEASE CONTACT US 561-955-8553

Student Name:

First NameLast Name

Gender

Race

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student Date of Birth

Date

Age

Student Cell Phone

Format: (000) 000-0000.

Student Email

example@example.com

School

Grade

SIS Student Number

SIS PW

How did you hear about PROPEL?

If it was a Friend, Who? Name?

First time PROPELIAN?

Permission to WALK / BIKE to AND / OR from PROPEL:

Extra-Curricular Activities: Please list any activities (clubs, sports, volunteering, jobs, family responsibilities, etc you are currently committed to after school. Note how many hours a week you are devoting to this activity.

Activity

Hours

Activity

Hours

Activity

Hours

Additional Notes

Parent / Guardian Name (1)

First NameLast Name

Relationship

Cell Phone

Format: (000) 000-0000.

Email

example@example.com

Parent / Guardian Name (2)

First NameLast Name

Relationship

Cell Phone

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact: (if different from persons listed above)

First Name

Last Name

Relationship

Cell Phone

Format: (000) 000-0000.

Email

example@example.com

HOUSEHOLD INFORMATION: (The following information is necessary for our records and makes it possible for us to apply for grants and funding to run programs for the students. The answers you provide are kept completely confidential. Your cooperation in providing this information is both appreciated and necessary Thank you.

of persons living in home

Languages spoken in household: (check all that apply)

Languages Spoken:

Student lives with: (check all that apply)

Student Lives With:

Yearly Household Income: (check one)

Household Income:

MEDICAL INFORMATION:

Please note that we are unable to administer or hold medications for your child as we do not have a nurse on site. Therefore, if medication (Epi-Pens, inhalers, etc) is needed your child must keep it in their bag and be able to administer it properly to themselves.

Does your child have allergies?

If yes, please list allergies (ex. bees, peanuts, dairy:

Does your child have an EpiPen?

List any medication your child is currently taking and the dosage

Does your child take medication during program hours?

MEDICAL AUTHORIZATION: In the event of a medical emergency, I authorize PROPEL staff to secure emergency medical treatment for my child if I cannot be reached immediately.

Any activity the student should be restricted from?

Primary Insurance Company

Name of Policy Holder

Policy Holder DOB

Date

(ex. child, dependent, other)

Patient's Relationship to Insured:

Other

Policy

Group

VAN TRANSPORTATION POLICY:

Transportation is provided for students in vans clearly marked with the PROPEL logo and colors. PROPEL students will be picked up from the designated pickup area at their school, at a specified time, and driven to the PROPEL facility. We expect your child to be on their best behavior while in our vans. They must sit down, talk quietly and follow the driver's directions. Failure to do so may result in suspension from the van, which will be given at the driver or staff's discretion. Should a member receive a suspension, that member will lose the right to ride in the van for a period of time. Van suspensions will be determined by the PROPEL staff.

PROPEL will provide students a ride home (with-in our radius) at the close of PROPEL programming for the day.

Van Rules and Expectations:

Backpacks should be taken off before sitting in a seat. Students must walk to and from the PROPEL van. Students must keep all hands and legs to themselves. Remain seated at all times. Students must use quiet voices when on the van: foul language will not be tolerated. Eating and drinking inside the van is NOT permitted. Parents/guardians will be responsible for the cost of repairs and damages caused by your child. Students must be on time for van pick up. The van will not wait.

Automatic Suspension from Van Privileges:

1. Physical threat or harm to other students and/ or the driver.

2. Fighting, smoking, drugs, or inappropriate touching while in the van.

3. Damage to property.

4. Bullying.

5. Belligerent behavior.

Consequences for NOT Following the Rules:

1. 1st offense: Staff will speak with the student.

2. 2nd offense: Driver/Propel staff will issue an incident report; parents will be notified. The student may be suspended from riding in a van for a defined period.

3. 3rd offense: Student will have van privileges permanently removed

Student Signature

Date

ParentGuardian Signature

Date

For Minor Child Name

Academic Release: I/we hereby give authorization/ permission to the Palm Beach County School District, Broward CountySchool District, Palm Beach County Schools, Broward County Schools and school personnel to obtain and release academicdata (report cards, progress reports, transcripts) and demographic data regarding my child to PROPEL personnel. Theinformation will be used for academic evaluation and assessment purposes.

Photo / Social Media / Marketing Release: I/we understand that my child may be photographed or videoed for programdocumentation and marketing purposes. I/we allow the above-named minor to participate in PROPEL activities and allowPROPEL and its partners to use photographs of my child for publicity purposes, including the PROPEL website, socialmedia, newsletters, and marketing releases.

Medical Release: I/we authorize PROPEL to obtain and give consent to emergency medical treatment. In the event thatI/we cannot be reached in an emergency, I give permission to emergency medical personnel to treat and transport my childas necessary for medical care, the emergency physician to hospitalize, secure treatment for, and order injections, and/oranesthesia, and/or surgery for my child.

In consideration for my child being permitted to participate in any PROPEL activities, I/we hereby release from liability andhold PROPEL harmless from any and all claims and causes of actions which might arise out of any activity conducted by orunder the control of PROPEL, its employees, administrator, agents, volunteers, Board of Directors or trustees, sponsors,and assigns (hereon referred to as Releases). Releasor(s)-(parent or legal guardian) agree to release, hold harmless andforever discharge Releases of and from any and every claim, demand, action or right of action, of whatsoever kind or nature,either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death orproperty damage resulting or to result from any accident which may occur as a result of participation in PROPEL or any activities in connection with PROPEL, whether by negligence or not.

Releasor(s) (parent or legal guardian) hereby assumes full responsibility for the risk of bodily injury, death or propertydamage due to the negligence of Releasees or otherwise while in or upon PROPEL property, vehicles, or otherwise whileinvolved in any PROPEL activity whatsoever and wherever.

Releasor(s) hereby agrees to indemnify the Releasees and each of them from any loss, liability, damage or cost they mayincur due to the presence of Releasor(s) in any PROPEL activity, upon any property occupied or used by PROPEL for itsactivities, any vehicles used in the course of and/or scope of PROPEL activities, whether caused by the negligence ofReleasees or otherwise.

Releasor expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive aspermitted by the laws of the State of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall,notwithstanding, continue in full legal force and effect

ParentGuardian Signature

Date

Name

First NameLast Name

Date

Waiver and Release