PROPEL YOUR FUTURE 

1600 NW 15th Vista Boca Raton, FL 33432

561-955-8553 WWW.PROPELYOURFUTURE.ORG

Fall 2024 - Summer 2025 Student Registration Form

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.

STUDENT Information: (please print clearly)

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.

Emergency Contact: (if different from persons listed above)

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.

Languages spoken in household: (check all that apply)

Student lives with: (check all that apply) Step-Mom

Yearly Household Income: (check one)

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

 

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

Does your child have any allergies? If yes, please list allergies:

Policy Holder's Date of Birth: 

Patient's relationship to insured (please circle): Child Other Dependent

The parent or legal guardian is hereon referred to as Releasor.

Academic Release: I/we hereby give authorization/ permission to the Palm Beach County School District, Broward County School District, Palm Beach County Schools, Broward County Schools and school personnel to obtain and release academic data (report cards, progress reports, transcripts) and demographic data regarding my child to PROPEL personnel. The information 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 program documentation and marketing purposes. I/we allow the above-named minor to participate in PROPEL activities and allow PROPEL and its partners to use photographs of my child for publicity purposes, including the PROPEL website, social media, newsletters, and marketing releases.

Medical Release: I/we authorize PROPEL to obtain and give consent to emergency medical treatment. In the event that I/we cannot be reached in an emergency, I give permission to emergency medical personnel to treat and transport my child as necessary for medical care, the emergency physician to hospitalize, secure treatment for, and to order injections, and/or anesthesia, 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 and hold PROPEL harmless from any and all claims and causes of actions which might arise out of any activity conducted by or under 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 and forever 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 or property 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 property damage due to the negligence of Releasees or otherwise while in or upon PROPEL property, vehicles, or otherwise while involved 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 may incur due to the presence of Releasor(s) in any PROPEL activity, upon any property occupied or used by PROPEL for its activities, any vehicles used in the course of and/or scope of PROPEL activities, whether caused by the negligence of Releasees or otherwise.

Releasor expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted 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.