Band of the Strong Program Registration Form
Please Return to this form to register for the variety of our programs.
Select the Program You are Signing Your Child Up For
Creative Nights (Monday's 6-7:45 pm Aug 24th - Dec 7th & Jan 25th - May 10th) - Ages 10-18
Fall Fishing Event (Sat Sept 19th) - Ages 10-18
Song-Writing Event (Sat Jan 30th) - Ages 10-18
Overnight at the Zoo (Fri-Sat Apr 1 & 2) - Ages 10-18
End of Year Showcase (Sat May - TBD) - Family Event
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code of Primary Address
Emergency Contact (Other than Caregiver)
First Name
Last Name
Emergency Contact (Other than Caregiver) Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child 1 Information
Name of Child 1
First Name
Last Name
Age
Gender
Ethnicity
Grade
School
Allergies
IEP/504 Information and Accommodations if Applicable
Medical Accommodations
Grief Symptoms Experienced
Distracted/problems thinking
Engaged in unhealthy activity to cope
Unable to fulfill important responsibilities (schoolwork, chores, etc)
Unable to positively engage with others
Feeling distressed, sad, in shock, and/or frequently cries
Excessively worrying, seems frightened or sensitive, overly tired
Feeling bitter, resentful, angry, blaming others
Feeling Confused, lost, unable to cope, and/or detached from others
Difficulty remembering things from the past, concentrating, remembering new information, etc.
Other
Other: Describe any other observations you have had of your child. All information can be helpful as we work with them.
Child Strengths, Interests, Anything Else Positive about Your Child
Image of Child
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Child 2 Information
Name of Child 2
First Name
Last Name
Age
Gender
Ethnicity
Grade
School
Allergies
IEP/504 Information and Accommodations if Applicable
Medical Accommodations
Grief Symptoms Experienced
Distracted/problems thinking
Engaged in unhealthy activity to cope
Unable to fulfill important responsibilities (schoolwork, chores, etc)
Unable to positively engage with others
Feeling distressed, sad, in shock, and/or frequently cries
Excessively worrying, seems frightened or sensitive, overly tired
Feeling bitter, resentful, angry, blaming others
Feeling Confused, lost, unable to cope, and/or detached from others
Difficulty remembering things from the past, concentrating, remembering new information, etc.
Other
Other: Describe any other observations you have had of your child. All information can be helpful as we work with them.
Child Strengths, Interests, Anything Else Positive about Your Child
Image of Child
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Child 3 Information
Name of Child 3
First Name
Last Name
Age
Gender
Ethnicity
Grade
School
Allergies
IEP/504 Information and Accommodations if Applicable
Medical Accommodations
Grief Symptoms Experienced
Distracted/problems thinking
Engaged in unhealthy activity to cope
Unable to fulfill important responsibilities (schoolwork, chores, etc)
Unable to positively engage with others
Feeling distressed, sad, in shock, and/or frequently cries
Excessively worrying, seems frightened or sensitive, overly tired
Feeling bitter, resentful, angry, blaming others
Feeling Confused, lost, unable to cope, and/or detached from others
Difficulty remembering things from the past, concentrating, remembering new information, etc.
Other
Other: Describe any other observations you have had of your child. All information can be helpful as we work with them.
Child Strengths, Interests, Anything Else Positive about Your Child
Image of Child
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Name of Person Who Died
First Name
Last Name
Relationship to Child/Children (Uncle, Aunt, Father, Mother, etc)
How Person Died
Natural Causes/Expected
Disease/Medical Complications
Unexpected/Sudden
We respect your privacy which is why the question above is very general. If there is more information about how the person died that you think would be helpful for us as we help your child, you are welcome to write it here.
Release of Information and Medical
Emergency Medical Release
Emergency Medical Treatment Release I agree to have my child receive any emergency medical services deemed necessary by the authorities in charge. I understand that the resulting expenses will be my responsibility as the child’s parent/guardian. I further agree to release, discharge and indemnify Band of the Strong, its Officers, Board of Directors, Employees, Agents, and Volunteers from any and all liability, damages, claims or causes of action, arising out of or in any way connected to the administration of emergency medical services.
Yes, I Agree to the Above
No, I Do Not Agree (If selected, the child may not attend the program)
Photo, Video, Audio Release
By selecting “I agree” below, I give Band of the Strong permission to photograph, video record, and audio record me and/or the child or youth participant listed on this registration form during programs, events, and activities. I also give Band of the Strong permission to photograph, display, reproduce, and share artwork, writing, music, recordings, or other creative work produced during the program. Band of the Strong may use these materials for educational, promotional, fundraising, research dissemination, social media, website, print, grant reporting, and other nonprofit-related purposes. I understand that: Materials may be edited, reproduced, published, or shared in print or digital formats. The participant’s full name will not be used publicly without separate permission. No compensation will be provided for the use of these materials. Participation in the program is not dependent upon granting this permission. I may withdraw permission for future use by contacting Band of the Strong in writing. Materials already published or distributed may not be able to be removed.
I agree to the photo, video, audio, and creative work release described above.
I do not agree. Please do not use identifiable photographs, video, audio recordings, or creative work from this participant for public or promotional purposes.
Concerning Behavior
If your child exhibits concerning behaviors or acts in a way that goes against our policies/expectations/group norms, we will call the caregiver listed above. If they do not answer, we will call the emergency contact on file. Please make yourself available by phone/text during while your child(ren) are in our care and let the emergency contact know that it's possible to receive a call from us. Please type your initials in the box below that you have read and agree to this policy.
Pick-Up Policy
I agree to pick up my child or arrange for them to picked up at the time the program ends. If I am going to be late, I will call 402-253-6502 to make the staff aware that I will be late.
Signatures and Date
Written Signature
Signature
Date
-
Month
-
Day
Year
Date
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