Student 1 Information
If you do not have access to internet, there is still an opportunity to participate in our programs. We will reach out directly to you for more information.
Student 2 Information
Student 3 Information
CONSENT FOR SERVICES/GENERAL RELEASE OF LIABILITY
I, the undersigned parent/guardian, agree that my child can participate in the services provided by East Austin Prep. (“EA Prep”). I understand and agree that my child’s participation in these services may be disclosed on a need to know basis to other entities engaged in providing services to my child.
I release EA Prep from all liabilities to my child for all damages, expenses (including attorney fees), claims, judgments, actions or causes of action as a result of any loss or injury to the person or property which my child may sustain or suffer during or arising out of services provided by EA Prep or transportation provided by EA Prep, whether caused by the acts or omissions of EA Prep officers, directors, employees, representatives, advisors, affiliates, divisions, departments, related entities, contractors, funding source and/or other agents (“Parties Released”). I agree to defend and indemnify the Parties Released from and against any and all liabilities.
I, the undersigned parent/guardian, hereby give my consent for the release of reports, stories, videos, or pictures (“Materials”) that may identify my child. These Materials may be used for educational, informational, promotional, marketing or other activities. I acknowledge EA Prep’s right to prepare the Materials for publication or other use, including cropping, altering or changing the Materials at its discretion. I hereby release the Parties Released from all claims and liabilities arising out of or in connection with the use of the Materials. I understand that I do not have a right to royalties or payment in any form for these Materials, neither today nor at any future date.
I hereby give permission for the participant(s) listed on this application to take part in the East Austin College Prep: ACE activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I understand that all of EA Prep policies and procedures are to be adhered in this program. My child is expected to behave appropriately at all times and follow the rules of your school. I also acknowledge that I have received the Parent Handbook, which describes the East Austin College Prep: ACE Program Behavior Management Policy in more detail.
I further give my consent to the school district and East Austin College Prep: ACE to share the participant’s student records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and /or East Austin College Prep: ACE will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program.
Vendor and/or Partner Information Sharing
East Austin College Prep: ACE contracts with non-EA Prep organizations to provide afterschool activities. I give the afterschool staff permission to release my child’s student ID # to EA Prep’s contracted program providers for the purpose of assessing program effectiveness. Only group data (i.e. information regarding state test scores, attendance, behavior, etc. for all the students in the program) will be examined, no data specifically connected to your student will be identified.
Photo / Video Taping ReleaseI give my consent to the East Austin College Prep: ACE program to take the participant’s photograph or videotape during program activities, to be used for educational and public relations purposes.
Text and Email Notifications
I give the afterschool staff permission to contact me through the Talking Points app for updates regarding summer programming, time/date changes, upcoming events, etc.
I am the parent/legal guardian of the minor named above and have legal authority to execute this consent & release. Grievances related to the program may be addressed by a phone call or conference with, the East Austin College Prep ACE Director, Boys & Girls Club Extension Director or school principal. For unresolved matters, please refer to EA Prep’s Student Handbook for additional resources and/or www.eaprep.org for school district protocol.
I agree that I have signed the consents on this form in exchange for my child’s participation in services provided by EA
Prep. Additionally, my signature affirms: (1) that I have read this document and have been offered a copy of this document; and (2) that the parent/guardian identified in this form is the parent or legal guardian of the child identified in this form.