Akoma Unity Center - Youth Drug and Alcohol Registration

Teen Mental Health First Aid Certification Program

Registration form for Akoma Unity Center - Anne Shirrells Park
General Information
Parent or Guardian #1*

First NameLast Name
Please Check one

In homeOut of home
Parent or Guardian #2

First NameLast Name
Please Check one

In homeOut of home
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Text messages ok?

YesNo
Number of scholars you want to register?*
If you are registering more than four, please complete another registration form.
Scholar 1
Scholar Name*
Gender*
Ethnicity / Race*
Birthday *

MonthDayYear
Date
Scholar Grade*
What school does your scholar attend?*
Student School ID*
Which School District?*
Scholars Gmail Address:*
Do you consent to the scholar participating in Google Classroom with the instructor?*

YesNo
Note: All scholars ages 11-18—no matter what school district are welcome to join! This program is completely FREE, and the best part? Scholars get paid to participate! Just bring your commitment to showing up for every class and completing homework on Google Classroom. Let’s learn, grow, and have fun together!
Preferred Language*

EnglishSpanishOther
Do you require translation or interpretive services?*

YesNo
Allergies / Asthma?*

YesNo
If yes, explain
Is your scholar vegetarian?*

YesNo
Medical Insurance Company / Policy Number
Regular Doctor and Phone Number
Does your scholar have any of the following circumstances? Check all that apply.*

Special EducationFoster YouthHomeless YouthEnglish Language LearnersNone of the Above
Scholar 2
Scholar Name*
Gender*
Ethnicity / Race*
Birthday *

MonthDayYear
Date
Scholar Grade*
Which class(es) are you registering for? Select all that apply*

Water Education Program (Drip’d Squad)STEAM RoboticsGraphic DesignGirl Scout Troop #1419Student Internship (16-17 y.o)Water EducationDocumentary Film ClubNature Based LearningTutoring
What school does your scholar attend?*
Student School ID*
Which School District?*
Scholars Gmail Address:*
Do you consent to the scholar participating in Google Classroom with the instructor?*

YesNo
Note: All scholars ages 11-18—no matter what school district are welcome to join! This program is completely FREE, and the best part? Scholars get paid to participate! Just bring your commitment to showing up for every class and completing homework on Google Classroom. Let’s learn, grow, and have fun together!
Preferred Language*

EnglishSpanishOther
Do you require translation or interpretive services?*

YesNo
Allergies / Asthma?

YesNo
If yes, explain
Is your scholar vegetarian?*

YesNo
Medical Insurance Company / Policy Number
Regular Doctor and Phone Number
Does your scholar have any of the following circumstances? Check all that apply.*

Special EducationFoster YouthHomeless YouthEnglish Language LearnersNone of the Above
Scholar 3
Scholar Name*
Gender*
Ethnicity / Race*
Birthday *

MonthDayYear
Date
Scholar Grade*
Scholars Gmail Address:*
Which class(es) are you registering for? Select all that apply*

Water Education Program (Drip’d Squad)STEAM RoboticsGraphic DesignGirl Scout Troop #1419Student Internship (16-17 y.o)Water EducationDocumentary Film ClubNature Based LearningTutoring
What school does your scholar attend?*
Student School ID*
Which School District?*
Do you consent to the scholar participating in Google Classroom with the instructor?*

YesNo
Note: All scholars ages 11-18—no matter what school district are welcome to join! This program is completely FREE, and the best part? Scholars get paid to participate! Just bring your commitment to showing up for every class and completing homework on Google Classroom. Let’s learn, grow, and have fun together!
Preferred Language*

EnglishSpanishOther
Do you require translation or interpretive services?*

YesNo
Allergies / Asthma?

YesNo
If yes, explain
Is your scholar vegetarian?*

YesNo
Medical Insurance Company / Policy Number
Regular Doctor and Phone Number
Does your scholar have any of the following circumstances? Check all that apply.*

Special EducationFoster YouthHomeless YouthEnglish Language LearnersNone of the Above
Scholar 4
Scholar Name*
Gender*
Ethnicity / Race*
Birthday *

MonthDayYear
Date
Scholar Grade*
Scholars Gmail Address:*
Which class(es) are you registering for? Select all that apply*

Water Education Program (Drip’d Squad)STEAM RoboticsGraphic DesignGirl Scout Troop #1419Student Internship (16-17 y.o)Water EducationDocumentary Film ClubNature Based LearningTutoring
What school does your scholar attend?*
Student School ID*
Which School District?*
Do you consent to the scholar participating in Google Classroom with the instructor?*

YesNo
Note: All scholars ages 11-18—no matter what school district are welcome to join! This program is completely FREE, and the best part? Scholars get paid to participate! Just bring your commitment to showing up for every class and completing homework on Google Classroom. Let’s learn, grow, and have fun together!
Preferred Language*

EnglishSpanishOther
Do you require translation or interpretive services?*

YesNo
Ethnicity / Race*
Allergies / Asthma?

YesNo
If yes, explain
Is your scholar vegetarian?*

YesNo
Medical Insurance Company / Policy Number
Regular Doctor and Phone Number
Does your scholar have any of the following circumstances? Check all that apply.*

Special EducationFoster YouthHomeless YouthEnglish Language LearnersNone of the Above
Additional Comments
How did you hear about this program?*

SchoolCommunity CenterSocial Media / WebsiteFriend / FamilyOther
WAIVER
My child(ren) can participate in outdoor/physical activities - Without Restrictions*

YesNo
Emergency Contact
Relationship to child(ren)
Work Phone
Please check the box*

("Picked Up") I (or an approved person I have listed on this application) will pick up my child(ren) on time from the Anne Shirrells Park Community Center.
Please check the following boxes to acknowledge your agreement*

1. I grant to Akoma Unity Center, San Bernardino City Unified School District and the City of San Bernardino, its representatives and employees the right to take photographs of my child(ren). I agree that Akoma Unity Center may use such photographs of my child(ren) with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. I have read and understand the above. I understand my electronic signature will be considered acceptance of the above mentioned waiver.2. I understand that if it is necessary for my child to take medication, or to allow my child to self-administer medication, during program hours, I recognize and acknowledge that there are certain risks of physical injury in connection with the administering of medication to or self-administration by my child. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and/or recognize an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services. I hereby acknowledge that the information provided is for the dispensing of medication for my child(ren) is accurate. I also understand that it is my responsibility to inform management or Academic Mentors of any changes in the dispensing of medication. I understand my electronic signature will be considered acceptance of the above mentioned waiver.3. I agree that my child(ren) may participate in surveys to determine how the program may better serve students and to provide data to obtain grants and grant funding. I have read and discussed the Akoma Unity Center agreement with my child(ren). My child(ren) and I know that he/she/they must remain under supervision in assigned areas and follow the directions of the staff at all times. I will notify the staff in a timely manner to keep the information on this application accurate and up-to-date. By signing this application, I agree that all the above information provided is true and correct. I also understand that my child's acceptance is on a first come, first serve basis, so enrollment into the program is not guaranteed. I understand my electronic signature will be considered acceptance of the above mentioned waiver.
Statement of Policy
- An Enrollment Form is required for all scholars participating in Akoma’s Youth Programs.
- Due to the COVID-19 Pandemic, it is critical that scholars be picked up before or promptly at to allot proper cleaning time after closing.
  Only persons authorized by the parent or guardian may pick up your child from Akoma Unity Center. Please notify the Site Program Manager in writing if anyone other than a parent/guardian will pick up your child.
- All scholars attending Akoma’s Youth Programs are required to follow all program rules. Behavioral problems will result in parent notification and possible suspension from the program.
I have read and understand the Statement of Policy contained here.*

Agree
Please verify that you are human*
Signature
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Teen Mental Health First Aid Certification Program