PARENT/Guardian CONTACT INFORMATION:
Address   Street Address   Suite/Apt/Unit   City      Zip   
Home Phone Area Code   XXX - XXXX  Cell PhoneArea Code   XXX - XXXX  
Work Phone Area Code   XXX - XXXX    

As legal guardian of the enrolled student: (student name)   First Name   Last Name   
Initial   I allow GEMS After-school Program to release information to school or program personnel regarding myself or my students progress, grades, attendance, issues, and other pertinent information. I allow GEMS After-school Program to release information for program evaluation purposes.  
Initial   I allow school and program personnel to release information to GEMS After-school Program regarding me or my student performance, progress, attendance and relationship with school or other program personnel.
Initial    I understand that information about myself, the above-named student, and/or my family will only be shared to assist my student or family in improving school or behavioral performance.
Initial   I understand that information shared about myself, the above-named student or my family is confidential and will be dealt with in a professional manner and kept in the strictest confidence.

Initial   PROGRAM CANCELLATIONS
We work very hard to make sure program is NOT cancelled. In the event that it is, we will notify the school and parents as soon as possible.
It is the parent’s responsibility to make sure the student is transported home from school if program is cancelled. Reasons for program cancellations may include, but are not limited to inclement weather, and school and/or building emergencies (i.e. power outage, school lock down, etc). If school is cancelled due to the weather, there will be NO GEMS After-school Program.

TRANSPORTATION RELEASE
Initial I agree and give permission for my student to attend and be transported to all field trips via transportation provided by GEMS After-school Program.

Initial One   My student is a PICK UP
A PICK-UP is a student or children who is picked up after the program by someone who walks or drives to get them.

PHOTO RELEASE
    Initial One   GEMS After-school Program has permission to photograph my student

• I hereby give GEMS After-school Program and its Partners permission to take photographs and/or video of the minor named above, or photographs and/or video in which the minor may be involved with others for the purpose of promoting their programs. I hereby release and discharge GEMS After-school Program and its Partners, and all program sponsors from any and all claims arising out of the use of the photos and/or video, or any right that the minor or I may have.

Initial One GEMS After-school Program CANNOT photograph my student for any reason and I will explain this to my student.

CLIENT RIGHTS HANDBOOK
Initial   I acknowledge that I have received a copy of GEMS After-school Program handbook (Family Packet). I agree to abide by and follow policies as stated within the handbook. I understand my rights (including those regarding confidentiality) as stated within the handbook.

ATTENDANCE & DISCIPLINE POLICIES AND INCENTIVES
Initial   I acknowledge that I have read and agree to GEMS After-School Program attendance and incentives policy as outlined in the GEMS After-school Program Family Packet. I agree to abide by and follow the policies as stated within the handbook. I understand that my student may be unable to participate in attendance incentives due to excused or unexcused absences during the school year.
GEMS After-school Program DISCIPLINE POLICY
GEMS After-school Program is committed to providing a safe environment where students can feel safe from the negative impact of crime & violence. In our program, we will address the issues of violence and teach students skills to develop peaceful solutions to conflict. To reinforce this goal, fighting and other acts of aggression will not be tolerated in our program. If a student chooses to engage in defiant, aggressive or violent behavior, the discipline policy will go into effect & GEMS After-school Program staff will enforce discipline policy.

• With the first incident, the student will be given a verbal warning to deter the behavior. If behavior continues student will be placed with their group leader. The incident will be resolved in a manner satisfactory to all parties involved. Parents will be informed. This is a first warning and it will be documented in the student’s file.
• With the second incident, the student will be placed with their group leader and the GEMS After-school Supervisor. The student cannot return to the group until the matter is resolved safely. Parents will be informed of this incident. This is a second warning and it will be documented in the student’s file.
• With a third reported incident, the student will be place with their group leader and will speak to the GEMS After-school Program Supervisor. The student may need to be picked up & to spend the next day at home, one day suspension from the GEMS After-School Program. This is the third warning and will be documented in the students file. A behavioral plan may be created with the parent & student in order to curtail future incidents/behaviors in order to help guide understanding/success.
• If three consecutive Suspensions occur in one Trimester, the student will be suspended from the GEMS After-school Program for the remainder of the school year.

Reasons a student may be removed from GEMS After-school Program include but are not exclusive to:

➢ Disobeying safety rules on the bus, on a field trip or at program thereby endangering themselves and others.

➢ Bullying, threatening or committing harm to self or others.

➢ Using a weapon (knife, gun, razor, etc…) or something used with intent as a weapon (a stick, rock, belt, rubber band, etc…)

Each incident of misbehavior will be dealt with on a case-by-case basis and will be resolved in a manner that is fair to both the student and to the other students in program. The focus of our program is the growth and safety of the students. We will work with all resources available to keep your student active in program. We recognize that you, the parent, are the most valuable resource in our work with your student. We will seek to include you in all goals and decisions involving your student.

Any student dismissed from GEMS After-school Program the previous school year must gain permission from GEMS After-school Program Administration before being allowed to enroll for GEMS After-school Program the following year.
InitialWAIVER OF LIABILITY

➢ I agree that the student named below and his/her parents/guardian and relatives will abide by the rules and regulations set by GEMS After-school Program for the health, safety, and welfare of all group participants.

➢ I agree that GEMS After-school Program is not responsible for the loss or damage of the below named student’s personal belongings by fire, theft, loss, etc. GEMS After-school Program is does not take responsibility for any electronic devices brought nor encourages bringing electronic devices to the program.

➢ I understand and acknowledge that certain activities that GEMS After-School Program participates in, whether listed in the family packet or not, have an increased risk of injury associated with them. I hereby release and agree to indemnify and hold harmless, GEMS After-school Program and all its personnel, volunteers and representatives whatsoever from any and all losses, claims, damages, liabilities, costs and expenses including attorney’s fees, may sustain or incur in any way arising out of or in connection with the below named student participation in any and all GEMS After-School Program activities.

By signing this document, I am certifying that I am the parent or legal guardian of the student whose name appears on this GEMS After-school Program registration form. I acknowledge that I have read, initialed and agreed to each of the above conditions.

I have received a GEMS After-school Program Family Packet and have been introduced to its contents as it pertains to my student’s participation and attendance in GEMS After-school Program. I understand the standards and their consequences as set forth by GEMS After-school Program and will educate my student and encourage him/her to behave in accordance with GEMS After-school Program standards and policies.

HEALTH HISTORY AND RELEASE:
Initial   Health History:
The health history given for    First Name   Last Name   the student named on this form is correct to the best of my knowledge.

• I give permission for the student named above to engage in all activities except as noted.
• In the event of an EMERGENCY, I hereby give permission to the medical personnel/physician selected by a GEMS Afterschool Program representative to provide necessary related transportation; to order treatment, x-rays, routine tests; and to release information necessary for insurance purposes or proper medical treatment for my student.
• In the event I cannot be reached in an EMERGENCY, I hereby give permission to the medical personnel/ physician selected by a GEMS After-school Program representative to secure and administer treatment, including hospitalization, for my student

Current Medications (name of drug, time taken, and dosage): Please provide a detailed description - mark "NA" if none.

Student First & Last Name:     First Name   Last Name    Student's School ID number:   ID #      
Parent / Guardian Name:   Name  Email Address:   Email    
School Name:   School Name   Grade: GradeBirth date:   Birth Date 
Student Address:    Street Address   Address Line 2   City   State   Zip         
Primary Phone Number: Area Code  Phone Number  Alternate Phone Number:   Area Code   Phone Number         

I hereby grant permission for      Student Name   to participate in the P4S, and grant permission to share my child’s program information (name, date of birth, student ID) with the P4S. I understand that information will only be shared about my child if it is relevant to my child’s education. The P4S may also request access to my child’s academic, attendance and behavior records for the current, prior, and future school years so that they can provide targeted services to my child and understand the impact of this program. I allow P4S partners to discuss information that supports the goals defined above, with school officials and approved representatives of other agencies that have consent.   

I understand that my child’s information will be kept confidential. I also understand that I am able to revoke this consent at any time in writing. I understand that my child’s personally identifiable information will not be shared with P4S funders. These funders include: City of Columbus, Franklin County Department of Job and Family Services, Franklin County Children Services, United Way of Central Ohio, and Nationwide Children’s Hospital.

I do not give permission for my child to participate in the P4S.