Enroll a child. Parent/caregiver name * First Name Last Name Relation to Student * Parent Grandparent Aunt/Uncle Other Parent/caregiver email * Parent/caregiver phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date * Today's Date: MM DD YYYY Student name * First Name Last Name Student gender * Male Female Student birthday * MM DD YYYY School * Current Grade * T-shirt size * Adult S Adult M Adult L Adult XL Adult XXL Adult XXXL Is the child suffering from any emotional, behavioral, mental, social, or academic issues? (if yes, please explain) * Is the child having any problems in school? (if yes, please explain) * Is the child taking any medications? (if yes, please list below) * Does the child have any health problems or disabilities? (if yes, please explain) * Does the child have a parent or relative in prison? * Yes No If the answer is yes to the above questions, is the child aware of the situation? Yes No Does the child's father live at home? Yes No Describe anything else you would like us to know about the child Does the child want a mentor? (In order to process the application it must be the child's choice to have a mentor) * Yes No Can the child commit to meeting with their mentor once a week for at least a year? * Yes No I grant Center for Champions volunteers permission to give my child a ride in their personal vehicle. I understand that volunteers will abide by the legal laws and seek the safety of my child at all times. (Transportation is only provided once CFC finds a match for your student and they get "officially" matched. * Please note that all drivers must submit a motor vehicle history check prior to receiving permission to transport students. Yes No I grant permission for my child to be in a mentoring relationship with Center for Champions staff and or volunteers. * Yes No Media Release: I hereby grant to Center for Champions and those acting under its authority, to record on film, tape or otherwise my child's and my name, likeness, voice, performance, and actions. I acknowledge that my child's or my performance may be edited as desired by Center for Champions and may be used in perpetuity and authorize others to use, such recording as Center for Champions sees fit on television and radio broadcasts, audio-visual use, in any production, in any and all media now known or hereafter devised throughout the world, and to use, license, market, and distribute in any medium or forum said productions and any other productions in which said recording may be incorporated. I waive the right to inspect or approve any such use of my child's name or my name, likeness, voice or actions, and hereby also authorize Center for Champions and those acting under its authority (mentors, REFs) to use my child's name or my name, likeness, voice, actions, biography, and/or composition for purpose of promotion and publicity in connection with the program material. Further, I hereby waive and forego any compensation for my appearance in the production. I release Center for Champions from all claims and liabilities of any kind arising out of or in connection with the making or uses of such films, videos, photos, or recordings. The rights granted herein shall insure to the benefit of Center for Champions, its licensees, successor and assigns. * Yes No Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the medical personnel selected by Center for Champions to order x-rays, routine tests, or treatment; to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips where participants are off site. * Yes No Medication Disclaimer: Center for Champions will not administer any medications during program hours. If your child needs to use an inhaler or any other necessary medication they will be responsible to self-administer those medications. Center for Champions will store the medication until it is needed, but no staff member will be able to administer the medication. All medications that are brought to Center for Champions must be brought in their original packaging with the prescription intact. IF YOUR CHILD NEEDS REGULAR MEDICATION DURING PROGRAM HOURS YOU WILL NEED TO CALL TO MAKE ARRANGEMENTS PRIOR TO THE FIRST DAY OF THE PROGRAM. * Yes No Permission to Participate: I give my child permission to participate in programs facilitated by Center for Champions during the times my son or daughter is in the care of Center for Champions. I understand that this permission covers the participation of my child with outside agencies visiting Center for Champions, as well as, their participation in field trips and off-site agency visits. I also understand that Center for Champions aims to provide safe, enriching and educationally sound activities and partnerships in order to facilitate student learning and growth. Any field trips or interagency collaboration would be in line with these goals. * Yes No Fighting/Physical Altercation/Leaving Premises/Vehicle * Though rare, occasionally students get into a fight or get upset with a mentor or staff member. If/when a student is violent and others can potentially get hurt, CFC staff will "block" the student from others and may even need to hold them back. Though we never intend to hurt a student we also don't want others to get hurt by a student who has lost control. At times, students have left the building when upset. Again, CFC staff will do our best to keep a student inside but we cannot physically force them. Should a student leave the premises we will contact caregivers immediately and we may contact authorities as well if any one, including the studen, is at risk of harm. CFC staff will do our best to keep a student in sight when they leave the building but we cannot guarantee this as a student may run. Lastly, on rare occasion, an upset student has left a vehicle. In this case, CFC staff and/or volunteers are instructed to contact the authorities first and then contact caregivers as this student may be in immediate danger. Volunteers/staff are instructed to try to monitor the student if possible but this cannot be guaranteed. Do you understand and agree with this policy? If no, please contact CFC staff to ask questions. Yes No Does your child have transportation to/from CFC (typically Thursdays from 6:30-8:30pm. Center for Champions does not provide transportation at this time. * Yes No OPTIONAL: Approximate household income? OPTIONAL: Ethnicity: OPTIONAL: Would you and your family consider yourself Christian? Yes No OPTIONAL: How did you hear about Center for Champions? Thank you! We’ll be in touch with you regarding your student enrollment to let you know if we currently have space available or if we need to add you to our waiting list.
