MLKFS Afterschool Application

Afterschool program Site; please select one:*

Martin Luther King Jr. Family Services King's Kids After School ProgramMLK Charter School of Excellence
Name*

Child's First NameChild's Last Name
Date of Birth*

MonthDayYear
Date
Age*
School*
School Dismissal Time*
Grade*
Parent Guardian First & Last Name*
Relationship to Child*
Address*

Address

Street Address Line 2

City ZipState / Province

Postal / Zip Code
Primary Telephone Number*
Alternate Number
Email Address*
example@example.com
2nd Guardian Name
2nd Guardian Relationship to Child
2nd Guardian Primary Number
2nd Guardian Alternate Number
Emergency Contacts:

Emergency contacts (excluding parents/guardians) are also authorized to pick up the child unless otherwise noted.
Emergency Contact 1 Name*
Emergency Contact 1 Number*
Emergency Contact 1: Relationship to child*
Emergency Contact 2: Name*
Emergency Contact 2: Telephone Number*
Emergency Contact 2: Relationship to child*
Emergency Contact 3: Name
Emergency Contact 3: Telephone Number
Emergency Contact 3: Relationship to child
Emergency Contact 4: Name
Emergency Contact 4: Telephone Number
Emergency Contact 4: Relationship to child

Single Program Verification Form
Child's Name*
Date of Birth*

MonthDayYear
Date
I ensure that my child is not enrolled in any other Seven Hills Foundation Voucher programs such as another after school program, before school program or day care provider.
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

RELEASE OF INFORMATION:

My child receives services from the Martin Luther King Jr. Family Services and I give permission for the Martin Luther King Jr. Family Services' King's Kids After School Program to exchange and receive information regarding my child and if applicable, myself, and family with the following agencies:

Please check boxes for authorization:
School*
Telephone Number
Fax Number
Physician's Name
Telephone Number
Agency
Agency Contact's Name
Telephone Number
Fax Number
I understand that the Martin Luther King Jr. Family Services staff will keep this information confidential. I further understand that this release is valid for the duration of my child's services with Martin Luther King Jr. Family Services and that I may cancel or restrict this release at any time without penalty. I understand the content and authorization I have given to Martin Luther King Jr. Family Service and the agencies listed on this document.
I authorize the exchange of the following information:

Medical HistorySocial HistoryIEP/ 504 PlanBehavior RecordImmunization Record
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Media Release
Media Release: Please check which applies

My child HAS PERMISSION to appear in media coverage, fundraising, and event photo sessions while participating in the King's Kids After School Program.My child DOES NOT HAVE PERMISSION to appear in media coverage, fundraising, and event photo sessions while participating in the King's Kids After School Program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Field Trips and Off-Site Activities

I give permission for my child to participate in all regularly scheduled activities, off site, local, and out of town field trips. I understand that I will receive a specific field trip permission form which must be signed and returned for any field trip which requires prior parental authorization and or fees. The program will provide in writing a list of scheduled activities and field trips.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parent Service Agreement and Notification

I understand that the Martin Luther King Jr. Family Services, Inc. is a multifaceted non-profit organization that partners with numerous organizations for various reasons. I understand that I and/or my child may be exposed to services, assessments, evaluations, and programs that are in alignment with the agency's mission and vision statements for the enhancement of the after-school program and my child's academic, social, and emotional success. I understand that I will be directly notified of services and activities that my child will be participating in and I will be given dates and time of activities.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Volunteer/Intern Permission Form

I understand that Martin Luther King Jr. Family Services is a training site for many local, regional, and state High Schools, Colleges, and Universities which provide volunteers and interns. I understand that all volunteers and interns receive a CORI background check, formal interview, and orientation prior to working with any children. I understand that volunteers and interns help with all program activities and duties assigned to them under the supervision of MLK staff. Duties include but are not limited to homework help, tutoring, escorting children throughout the program site, reactional activities, and field trips.

I give my child permission to participate in and receive services with program volunteers and interns.
ParentGuardian Signature*

Clear
Date*

MonthDayYear
Date

Release of Liability: Please read before signing
In consideration of being allowed to participate in any way in the Martin Luther King Jr. Family Services, Inc. or MLK Charter After-School Program or Summer Camp program, its related events and activities, undersigned, acknowledge, appreciate and agree that: The risk of injury from the activities involved in this program does exist, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of injury does exist; and, 1. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation and, 2. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Agency immediately, and, 3. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin. HEREBY

RELEASE INDEMNITY, AND HOLD HARMLESS THE MARTIN LUTHER KING JR. FAMILY

SERVICES, INC. their officers, officials, agents, and / or employees, other participants, sponsoring agencies, sponsors, advertisers, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FULLY

UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Child's Name*
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnity and hold harmless the Releases from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
Parent/ Guardian Name:*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

PARENT TRANSPORTATION REQUEST FORM

Complete if you are requesting 1 or 2 way transportation for you child.
In limited circumstances, subsidized families may be approved for transportation between home or school and child care. Subject to funding availability, programs will be reimbursed at the Department of Early Education and Care (EEC) approved rate for one way or round trip transportation, based on a family's need. Subsidy Administrators must assess and document the parent's need for transportation, taking into consideration such factors as: (1) the availability of public transportation; (2) whether a parent has a car; (3) any physical incapacity of the parent that may prevent the parent from transporting the child; and (4) whether the parent's work schedule prevents transportation of the child to or from care. A family who lives within one half (1/2) mile of the provider will not receive transportation funding, unless exceptional circumstances exist. Please refer to the EEC Financial Policy Guide for guidance.
Parent/ Guardian Name (If requesting transportation)
I am requesting transportation services for my child(ren). I confirm that:

I live more than one half (1/2) mile from the programI do not have access to a vehicleI do not have access to public transportationI have a verified disability/special need that prevents me from transporting my child(ren) (*The disability must be verified in writing by a Physician, Psychiatrist, Psychologist, Nurse Practitioner or Psychiatric Nurse on the letterhead of your health care practitioner.)My work schedule prevents me from transporting my child(ren) to or from care.
Full Names & D.O.B of children you are requesting transportation for
I am requesting:*

One way transportationTwo way transportationOther/ I am NOT requesting afterschool transportation
I understand that providing false or misleading information in connection with this request for transportation may result in termination of my child care subsidy and an obligation to repay the cost of child care. I have been informed that transportation is subject to funding availability and may be terminated without prior notice.

Clear
Date*

MonthDayYear
Date

Single Program Verification Form

Health and Medical Information and Consent

Consent for Medical Care

Release of Liability: Please read before signing

THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF EARLY EDUCATION AND CARE Transportation Plan and Authorization

PARENT TRANSPORTATION REQUEST FORM

AFTERSCHOOL PROGRAM FUNDING STATUS NOTICE