SCC Application: Afterschool Program

SMOKETOWN COMMUNITY CENTER NEXT GENERATION PROGRAM APPLICATION & CONSENT FORM
Student Information
Student Name:*

First NameMiddle NameLast Name
Student Birth Date*

MonthDayYear
Student Gender at Birth:*
Student Race:*
Student Grade Level*
Parent/ Guardian Information
Parent Name*

First NameLast Name
Phone Number:*

Area CodePhone Number
E-mail Address:*
Your Email Address
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Alternate Emergency Contact Name:*

First NameLast Name
Alternate Emergency Number*

Area CodePhone Number
Household*
$1 - $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000Above $50,000
YesNo
YesNo
If yes, please describe your child's health needs and necessary precautions. Provide medication names, dosage, frequency and any special considerations.
Participant's Health Insurance Provider:*
Participant's Health Insurance Policy Number:*
My child will walk to / from the program.My child will be dropped off / picked up from the program.
Full Name of who IS authorized to pick up your child:*
Full Name of who is NOT authorized to pick up your child:*
Is there any other information about your child that you believe would be helpful for program staff to know?
RELEASES
YESNO
MEDICATION/ EMERGENCY MEDICAL TREATMENT RELEASE: If my child requires medication during the program, I will provide detailed instructions to the program staff, including dosage, frequency, and any special considerations. In the event that I, or the emergency contact listed, cannot be reached in the case of a medical emergency, I authorize the program staff to seek medical treatment for my child.

YESNO
RECORDS RELEASE:I agree to allow the Smoketown T.E.A.M.S Program to collect grades, test scores, attendance discipline referrals, demographics and teacher surveys regarding my child's performance. I understand that all records and information regarding services are protected by confidentiality regulations governing the exchange of such information. The following agencies: Jefferson County Public School (JCPS) have my written consent to share information of a confidential nature among themselves in written or verbal form about my child.

YESNON/A - IN SUMMER PROGRAM
YESNO
PARTICIPATION RELEASE: As the parent/guardian, I hereby give consent for my child, to participate in the Smoketown Community Center Afterschool program organized by Blueprint 502. I understand that the program will take place at the Smoketown Community Center and Blueprint 502 and may include planned field trips for participants. Assumption of Risk and Release of Liability: I acknowledge that participation in the program involves inherent risks, including, but not limited to, physical injury and exposure to new environments. I release Smoketown Community Center and Blueprint 502, its staff, and volunteers from any liability arising from my child's participation.

YESNO
Parent/ Guardian Initials:*
Date*

MonthDayYear
Date
Should be Empty:

SMOKETOWN COMMUNITY CENTER NEXT GENERATION PROGRAM APPLICATION & CONSENT FORM

Student Information

Parent/ Guardian Information

RELEASES