SOCIAL KNIGHT PROGRAM

SOCIAL KNIGHT PROGRAM APPLICATION

NORTH JERSEY OUTREACH

Please note: The staffing ratio for Social "Knights" is 3:1. This program is intended for students with the ability to follow 2-step directions within the school and community setting, as well as communicate basic needs.

Payment is expected upon acceptance due to limited program capacity.

$100 per week
$55 for a 3 hr session

Please Choose Session Type

Please Choose Your Week(s) (Program runs Tuesdays & Thursdays )

Please enter day(s) and times

Child's Name

Child's Address ( Street Address, City, State )

Child's Phone Number

Parent/Guardian Names

Parent/Guardian Contact Numbers

Medical Conditions / Treatments / Medications

Allergies

If yes, please explain the allergy and treatment.

Emergency Contact Information:

Emergency Contact Name:

Emergency Contact Phone Number:

2nd Emergency Contact Name:

2nd Emergency Contact Phone Number:

In case of emergency and none of the above list names cannot be reached, I hereby give permission to the staff of North Jersey Outreach, to authorize emergency medical treatment for my child.

Payment:

Amount:

(Make checks payable to North Jersey Outreach)

Parent / Guardian Signature:

( Continue to Permission Form )

SOCIAL KNIGHT PROGRAM

MEDICAL FORM

Child's Name

First NameLast Name

Child's Date of Birth:

Liability / Medical Release

I, the undersigned parent or legal guardian, release North Jersey Outreach, or any other person acting on my behalf, from liability for any bodily injury sustained and loss or damaged of any personal article while on the premises or participating in any activity sponsored by North Jersey Outreach. I also permit North Jersey Outreach to seek medical treatment as deemed appropriate through EMS/911 and/or local hospitals.

Parent/Guardian Name

Date:

Parent/Guardian Signature

Photo / Media Release

North Jersey Outreach has my consent to photograph and/or videotape my child for public relations or internal publications.

Dismissal Information

My child, the undersigned, may be released from After Hour Kid Power sponsored by North Jersey Outreach to the following people:

Child's Name

Name

First NameLast Name

Relationship

Phone Number:

Name

First NameLast Name

Relationship

Phone Number:

Name

First NameLast Name

Relationship

Phone Number: