ICCS TeenREACH Summer Program Registration

ILLINOIS COALITION FOR COMMUNITY SERVICES
Teen REACH Summer Program Registration Form
ICCS offers your community a FREE Summer program, serving students 11-17. Your child can participate in sports, arts & crafts, STEM, and service-learning activities. A free lunch is provided! For more information contact our Program Coordinator, Holley Myers, holley@iccscares.org. or 812-629-8831 We look forward to hearing from you.
Please complete the following (one for each child):
Child's name:
Does your child go by a different name/nickname?
Child's Date of Birth:

MonthDayYear
Date
Child's Age:
Gender:

MaleFemaleNon-binary
Race:

American Indian/Alaskan NativeAsianBlack/African AmericanHawaiian/Pacific IslanderMultiple RacesWhite
Grade this school year:
PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian #1 Name:
Cell:
Format: (000) 000-0000.
Home:
Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
E-Mail:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Name:
Cell:
Format: (000) 000-0000.
Home:
Format: (000) 000-0000.
Work
Format: (000) 000-0000.
E- Mail
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Emergency Contact #1:
Emergency Contact #2:
Does your child have any allergies?
If yes, what allergies do they have?

Does your child have any medical concerns? Please explain:
Is there anything else you would like for the ICCS team to know about your child?
ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM
I hereby assume all of the risks of my child participating in any/all activities associated with the After-School Matters Program including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.
I acknowledge that this Accident Waiver and Release of Liability Form will be used by ICCS and that it will govern mine/my child's actions and responsibilities at said activity.
I waive, release, and discharge from any and all liability ICCS' directors, officers, employees, volunteers, representatives, agents, activity holders, sponsors and volunteers from any liability arising from the negligence or fault of the entities or persons released for death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur.
I indemnify, hold harmless, and promise not to sue the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.
I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.
I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.
The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I certify that I have read this document and I fully understand its content. I am aware that this is a release of liability and a contract, and I sign it of my own free will.
Name of Child
Parent/Guardian Signature
Date

MonthDayYear
Date
AUTHORIZATION TO OBTAIN AND REVIEW STUDENT RECORDS
I authorize the release of the following information to Illinois Coalition for Community Services on a quarterly basis: IEP, grade point average, photocopies or report cards, school attendance rates, grade achievement information and promotion/graduation information. I authorize the release and exchange of all pertinent information relating to contact with school counselors. I understand that I may revoke this consent at any time (revocation must be in writing). I understand that no revocation of this consent shall be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications.
Parent/Guardian Signature
Date

MonthDayYear
Date

Parent/Guardian Consent Form for TeenREACH Field Trips
The Charleston area and surrounding areas communities offer many valuable, educational resources to share with our students. Some examples may include but not limited to, Eastern Illinois University, Charleston Police Department, Charleston Fire Department, Sarah Bush Lincoln Hospital, Coles County Airport, local businesses, and local parks/attractions.
We will be taking advantage of these resources to occasionally taking the students on field trips to various locations during their time at TeenREACH. Transporation for these trips will be in the form of walking or busing. While in transit students will be supervised by the Program Coordinator, trained mentors, and interns. Families will be notified via Program Coordinator, Holley Myers, in advance of any scheduled outings. Families will be provided with trip information, dates, times, and location.
Please provide the below information to provide your consent for your child to attend potential field trips.
I,
give permission for my child, to participate in TeenREACH local off campus field trips, whether be walking or busing.
Consent for child to attend potential field trips

YESNO
If yes, I understand that I will be motified in advance if my student has the option to participate in DIWLS REIP. I lao unswearNS RHr my arusnwr qill bw aupweciaws at all timesby Teen REACH staff (program coordinator, mentor, or intern).
I give permission for my student to be photographed while participating in any TeenREACH activities, including field trips. Photos may be used for social media publications, flyers, newsletters, excluding my student's name.
Permission for student to be photographed

YESNO
Child's Name
Parent/Guardian Signature:

All information contained herein is confidential and is for ICCS tracking and reporting mechanisms.
Pursuant to the Charleston Community Unit District #1 policies permitting community organizations to reach a larger audience through the schools, attached is an informational sheet regarding the Illinois Coalition for Community Services. The views expressed in the attached advertisement are solely those of the Illinois Coalition for Community Services and do not reflect the views of or are not endorsed by the school district, any of the Board members, administration, faculty staff or any other persons associated with the school district in any way.
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ILLINOIS COALITION FOR COMMUNITY SERVICES

Teen REACH Summer Program Registration Form

PARENT/GUARDIAN CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM

AUTHORIZATION TO OBTAIN AND REVIEW STUDENT RECORDS

Parent/Guardian Consent Form for TeenREACH Field Trips