K-8 After School 2026-2027 Application

Emergency Contact / Parental Consent Form

We will request an update to this portion of the form every 6 months. Do let us know if emergency contact information changes before then!
Emergency Contact Persons

Please provide at least two emergency contacts that are NOT a parent/legal guardian.
Emergency Contact 1 (not a Parent/Guardian)

First NameLast Name
Emergency Contact 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 (not a Parent/Guardian)

First NameLast Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 3 (not a Parent/Guardian)

First NameLast Name
Emergency Contact 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Release

Please provide at least two people to whom your child can be released from program, other than a parent/guardian. If your child is an authorized release person to a sibling in program, you are required to include their information.
Authorized Release 1 (not a parent/guardian)

First NameLast Name
Authorized Release 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Release 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Release 2 (not a parent/guardian)

First NameLast Name
Authorized Release 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Release 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Release 3 (not a parent/guardian)

First NameLast Name
Authorized Release 3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Release 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child(ren)'s Medical Information
Name of Physician/Medical Provider

First NameLast Name
Physician/Medical Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician/Medical Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Provider
Policy Number
Emergency Consent

Parent/Guardian signature required for each item below to indicate parental consent.
Please sign to give consent for your child to receive emergency medical care if needed.
Please sign to give consent for your child to receive the administration of minor first-aid procedures.
In case of a medical emergency, I understand that my child will be transported to the hospital as the local emergency resource (police, EMS, fire, etc.) deem necessary.
In hereby assume full financial responsibility for any medical attention or treatment provided, as well as transport.
It is understood that in some medical emergencies, staff will need to contact the local emergency resource before contacting the parent, child's physician, and/or other adults acting on the parent's behalf.
Field Trips

In order for your child to attend trips beyond our program neighborhood, you must sign a permission slip that staff will distribute in advance.
Consent for children to participate in field trips if, and only if, a permission slip is signed in advance.
Please sign to give consent for your child to go on neighborhood trips with program staff (i.e. MLK Park, Hank Gathers, Helen Brown Community Center, Sanctuary Farms, etc.).
I hereby authorize HLCCTL K-8 Program to transport my child to and from the Honickman Center for field trips by Van, Bus, or Walking.
Sanitizer & Topical Ointments
I understand that my child will utilize hand sanitizer in their classroom and other areas of the building and/or while on trips.
I understand that my child may utilize sun screen and/or insect repellant while engaging in outdoor play and/or on trips.
Parent/Guardian Responsibilities
I understand that HLCCTL reserves the right to refuse participation program or its activities for reasons that include but are not limited to the following: poor behavior/excessive redirection, risk of health/safety to themselves or others, acts of violence, theft, profane language, lack of attendance or lack of ability to provide accommodations, etc.
I have read this release, acknowledge, and understand all of its terms.
Signature
Date

MonthDayYear
Date
Project HOME Image Release Form
Project HOME Image Release Form

Definition of “Personal Image”
In this form, “Personal Image” means any:
• photograph, film, video, sound recording, or drawing that depicts the image, likeness or voice of my child; or
• any edited or modified version of the above; or
• my child’s name

Grant Project HOME Right to Use Personal Image
I, on behalf of my minor children, grant to Project HOME the right and license to use, copy, modify and display the Personal Image in any medium (example- written or electronic) for its promotional or operational efforts.

Types of Uses by Project HOME
This right includes the right to use my child’s Personal Image in Project HOME’s:
• newsletter, mailings, promotional and fundraising materials, paper or electronic publications, web pages, social media and networking sites, films, videos, and other similar works.

No Compensation
I understand that neither I, nor my minor children, will receive any money or other compensation for use of any Personal Image.

No Right to Approve use or Personal Image
I understand that neither I, nor my minor children, will have the right to inspect or approve any Personal Image or any edited or modified version of any Personal Image.

Waiver and Release of Any Liability
I, on behalf of my minor children, hereby release and hold harmless Project HOME and its agents and employees from and against any claims related to the use of any Personal Image, such as any editing, blurring, or alteration, either intentionally or otherwise, that may occur in its publication or distribution.

Right in Perpetuity
I understand that this right continues unless I change my permissions in writing to the Program Manager, or Building Director, or the Development at Project HOME.
I have read this form, and I fully understand its meaning and effect, and I:
Your Signature
Date

MonthDayYear
Date
Biometrics / Security Camera Consent

This Security Camera Consent (this “Consent”) is by and between Project HOME and its affiliates (collectively “Project HOME”) and the undersigned.By signing this Consent, I understand and agree that Project HOME utilizes a cloud-based security system with facial recognition software provided by a third-party vendor for purposes of verifying identity and securing and controlling access to our buildings (the “Security Cameras”). The Security Cameras leverage algorithmic systems that may collect, capture, or otherwise acquire certain information about facial geometry, or other bodily features, that constitute biometric data or identifiers under some laws or regulations.I expressly agree that the Security Cameras may collect and process your information, including any facial geometry or other biometric data, so that Project HOME may secure and control access to its buildings; ensure the safety of its inhabitants and personnel; prevent and deter theft; investigate any incidents, unauthorized access, or other issues; and as otherwise necessary and appropriate. I further agree that the vendor of the Security Cameras may use your information to train the algorithms and software used to power the Security Camera. I further agree to the terms of Project HOME’s Privacy Policy.
I,First & Last Name (full name of parent/legal guardian ), have legal custody of the child(ren) listed below and consent to the collection, processing, storage, and disclosure their data in accordance with the terms set out above.
Child 1 Name

First NameLast Name
Child 2 Name

First NameLast Name
Child 3 Name

First NameLast Name
I have read this form, and I fully understand its meaning and effect, and I:
Your Signature
Date

MonthDayYear
Date
Non-Discrimination Clause

The K-8 Program at Honickman Learning Center Comcast Technology Labs will not discriminate against any participant based on factors like race, color, religion, sex (including gender identity and expression), national origin, disability, age or any other protected characteristic in its admissions, program services, or employment practices. This ensures equal access to participate in all aspects of program and fair treatment for all children in the program. We provide reasonable accommodation for children with disabilities to ensure equal participation.
FERPA

Under FERPA (Family Educational Rights and Privacy Act), after school programs can access student data from a school if they are considered a "school official" with a "legitimate educational interest," meaning they need the information to fulfill their educational responsibilities in supporting students. The program adheres to privacy guidelines when handling this information. Our K-8 program maintains the confidentiality of student data they receive from the school and follow our organization's data security practices to protect personal information.
If documentation is needed from the school for the collection of required data, do you give us consent to contact the school to receive the documentation on your behalf?

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