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  • COVENANT FREEDOM SCHOOL

    Scholar Enrollment Form

  • Thank you for your interest in Covenant UMC Freedom School!

    Please complete a separate enrollment form for each child. If you have questions or experience any issues submitting your form, call (937) 324-3501.

  • CHILD INFORMATION

  • *Birth Date:*
     - -
  • *Child's Level:*
  • *Child's Race/Ethnicity (check all that apply):*
  • *Gender Identity:*
  • Preferred pronouns:
  • *What is your child's Reading Proficiency level?*
  • *Is your child an English Language Learner? (English is not their first language)*
  • *Type of school that your child attended this past school year:*
  • *Does your child receive or qualify for free/reduced price lunch at school during the academic school year?*
  • *Has your child ever attended a Covenant Freedom Schools Summer program before?*
  • *Does your child have health insurance?*
  • *If yes, what is your child's health insurance carrier?*
  • *Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?*
  • *Fields with an asterisk (*) are required.

  • CHILD INFORMATION CONTINUED

  • FAMILY INFORMATION

  • *Relation to Child(ren):*
  • *Is this individual a legal guardian?*
  • *Gender Identity:*
  • *Preferred pronouns:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT INFORMATION

  • *Is this person authorized to pick up the child(ren) you enrolled in the program?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Rows
  • In case of an emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.
  • Date:
     - -
  • I understand that the organization that is enrolling my child(ren) in the CDF Freedom Schools program is in partnership with the Children's Defense Fund to offer this summer program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic information on children served and to report out this information in aggregate form.
  • *Date*
     - -
  • *Fields with an asterisk (*) are required.
    • Parent/Guardian Consent & Media Release 

    • I, {lastname}(Parent/Guardian's Name), give permission to the Children's
      Defense Fund ("CDF") and its designees to collect and record data on my child(ren),
      __________________________{child039sname}____________ (Child's or Children's Names). This data gathering may
      include, but is not restricted to, the following:

       Surveys and/or interviews about his/her/their knowledge, attitudes, skills and behaviors in regard to his/her/their academic development such as motivation to read; nonacademic development such as leadership and conflict resolution skills; and overall satisfaction with the CDF Freedom Schools program.

       Academic assessments and school data from report cards. These will be collected minimally twice: either shortly before the program begins, during the program, or shortly after the program ends.

      I understand that the purposes of these surveys and interviews are to document the impact of the CDF Freedom Schools program on its participants and to identify areas for improvement. I also understand that this information will remain private, and that only my child(ren)'s site director(s) and research assistants approved by the Children's Defense Fund will be able to look at his/her responses.

      I also understand that my child(ren)'s responses will be automatically grouped together with the responses of other CDF Freedom Schools sites for any public presentations of findings, and that my child(ren) will not be individually linked to his/her/their responses. In addition, I understand I can take back
      my permission at any time.

       

       

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