Lake Hills Art and Science Club

Lake Hills Art and Science Club

3rd, 4th, and 5th grade | January 20th - March 20th | Thursdays and Fridays, 2:30 PM - 4:30 PM | Room 101 (Art Room) | If your student is selected through the lottery, they will be automatically assigned to one of the club days.
Please note

Completion of this form does not guarantee your student will be added to this club. Our clubs have limited space for students. If needed, Jubilee REACH will utilize a lottery system to help determine who will participate. This ensures equality and fairness for all, regardless of technological access.
Student Information
Participant's legal name*

Participant First NameParticipant Last Name
Participant's preferred name*

Participant Preferred First NameParticipant Preferred Last Name
Participant grade level*

3rd grade4th grade5th grade
Classroom Teacher*
Participants Student ID Number*
Parent/Guardian Information
Parent/Guardian Full Name #1*

Parent/Guardian #1 First NameParent/Guardian #1 Last Name
Parent/Guardian #1 Relationship to Participant*
Parent/Guardian 1 Relationship to Participant
Parent/Guardian #1 Preferred Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 Email Address*
Parent/Guardian 1 Email
Parent/Guardian #1 Home Address*

Parent/Guardian 1 Street Address

Parent/Guardian 1 Street Address Line 2

Parent/Guardian 1 CityState / Province

Parent/Guardian 1 Postal / Zip Code
Parent/Guardian Full Name #2

Parent/Guardian 2 First NameParent/Guardian 2 Last Name
Parent/Guardian #2 Relationship to Participant
Parent/Guardian 2 Relationship to Participant
Parent/Guardian #2 Preferred Phone Number
Parent/Guardian 2 Phone Number
Parent/Guardian #2 Email Address
Parent/Guardian 2 Email
Parent/Guardian #2 Home Address

Parent/Guardian 2 Street Address

Parent/Guardian 2 Street Address Line 2

Parent/Guardian 2 CityState / Province

Parent/Guardian 2 Postal / Zip Code
Emergency Information

Emergency Contact, Student Medical Needs, etc.
Emergency Contact Name *

First NameLast Name
Emergency Contact Relationship to Family*
Emergency Contact Relationship to Family
Emergency Contact Preferred Phone Number*
Emergency Contact Phone Number
List Any Student Allergies or Dietary Restrictions
Allergies/Dietary Restrictions
Please Note:

Even if your student keeps medications/medical supplies at your school, Jubilee REACH staff members do not have access to the nurse's office after school.
List Any Medical Needs
If your student needs frequent access to medical supplies (e.i. inhaler, EpiPen, etc.) your student will need to self-carry these items.
Transportation
After club my child will:

Parent pick-upBusWalk (3rd grade and up only)Go to "Boys and Girls Club" (bus there)Right at SchoolJubilee REACH AM/PM (must be currently enrolled in AM/PM)
AFTER CLUB: If you are choosing more than one option, please leave instructions on when your student should use each mode of transportation.
My child can be picked up by the following individuals: (please list first & last name of individual).
Authorized pick-up individuals
If applicable, please list any individuals who are NOT allowed to pick up your child. If this does not apply, leave blank.

Participation Agreement

I, the legal guardian, grant permission for my child to participate in all Jubilee REACH programs and activities. I assume all risks and hazards incidental to such participation, and I do hereby waive, release, absorb, indemnify, and agree to hold harmless Jubilee REACH and all staff, managers, organizers, sponsors, supervisors, participants, and persons transporting my child to and from activities, for any claim arising out of an injury to my child, whether the result of negligence or for any other cause.If my child or I become injured or ill while at the Jubilee REACH Center or during any Jubilee REACH program, I grant permission for Jubilee REACH staff and volunteers to administer minor first-aid and seek emergency assistance at such time as either parent or legal guardian cannot be contacted in person or by telephone. I give my consent to any x-ray, examination, anesthetic, medical or surgical diagnosis and treatment, dental care, and hospital care which is deemed advisable by and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.I give permission to authorized, licensed representation of Jubilee REACH to provide transportation in authorized vehicles for my child and me to participate in field trips, events, travel to the Jubilee REACH Center, to home, or to transport my child and me in the event of a weather or medical emergency.I also authorize the program staff to communicate with my child’s school about my child’s homework, assignments, progress, and concerns.I agree to indemnify, defend, and hold Jubilee REACH harmless from any claims, causes of action, costs (including, without limitation, reasonable attorney’s fees) and any other liabilities of any nature related to any property that is lost or damaged while participating in a Jubilee REACH program or event.
Non-Discrimination

Jubilee REACH complies with all federal laws, rules and regulations and does not discriminate on the basis of race, color, national origin, gender or disabilities in student education programs, co-curricular activities, or employment policies. The district is an equal opportunity/affirmative action employer encouraging application of qualified minorities, women and disabled persons for employment and other opportunities. Jubilee REACH is a drug free/smoke free workplace and educational setting. Please direct inquiries regarding compliance, grievance or appeal procedures to Jubilee REACH.
Student Data

The parties agree that parents are primarily responsible for compliance with the Children’s Online Privacy Protection Act (COPPA), the Family Educational Rights and Privacy Act of 1974 (FERPA), and other applicable laws and regulations regarding the distribution of information regarding students (collectively, the “Privacy Laws”). Parents agrees to indemnify, defend and hold Jubilee REACH harmless from any claims, causes of action, costs (including, without limitation, reasonable attorney’s fees) and any other liabilities of any nature related to Privacy Laws except where such claims, causes of action, costs and other liabilities arise from the acts or omissions of Jubilee REACH. For purposes of parent meeting its obligations under the Privacy Laws, Jubilee REACH agrees that it will employ reasonable protections to prevent unauthorized access to personally identifiable student information in Jubilee REACH’s control. Jubilee REACH will not disclose personally identifiable information from education records to third parties without the prior consent of the Parent and the Parent or student, will use such information only for activities related to this agreement, and will delete or destroy such information following termination of this agreement or earlier if requested by parents. Jubilee REACH may retain and use anonymous demographic and statistical data and information (not individually identifiable to the geographic area, school, city, the parent or any individual) it collects pursuant to this Agreement to improve its Products or for any other purpose but will comply with all applicable laws and regulations.
Photography/Video Release

From time to time, your child's school and the school district create videos and photographs of our participants and their schoolwork or sports and activities in which they are involved. Occasionally, video and photographs of our participants, their class activities, sporting events, student work, and other student creations are used outside of the district and on district or Jubilee REACH websites.

Examples of these uses are:
- To show the Bellevue community what we do in our programs; to include in media; to make presentations to other audiences.
- Your child may be included in video or in photograph that could be used for such activities, but you have the option to withhold your permission. By signing below, you are giving permission to Jubilee REACH and Bellevue School District to take and use your child’s photograph or use video footage of you and your child and statements made by you and/or your child to be used for Jubilee REACH or Bellevue School District editorials, fundraising, advertising, and promotional purpose.
I give my permission to release photographs/videos of my student.*

YesNo
Are you interested in learning more about volunteering with Jubilee REACH?

I am Interested in volunteering with my child's club and would like more information.I am not interested in volunteering at this time.
Please note

This form only needs to be filled out once and will remain valid and in effect until changed by parent/guardian. The District and Jubilee REACH cannot guarantee the complete removal of a child’s information from every site on the Internet due to the ease of creating links to and copying material from the Internet.
I hereby certify that I am the parent or guardian of the student, named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.*

YesNo
Parent/Guardian Signature*

Clear
Should be Empty:

Lake Hills Art and Science Club

Please note

Student Information

Parent/Guardian Information

Emergency Information

Please Note:

Transportation

Participation Agreement

Non-Discrimination

Student Data

Photography/Video Release

Please note