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.

$20 per hr
$25 per hr with a personal aide
$45 for a 3 hr session
$55 for a 3 hr session with a personal aide

Per Hour3 Hour Session

Week 1 - 4/26 & 4/28Week 2 - 5/3 & 5/5Week 3 - 5/10 & 5/12Week 4 - 5/17 & 5/19

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*

NoYes

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:*

YesNo

CashCheckCredit Card

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

YesNo

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: