Resilient Kids Program Registration

Today's Date

Student Information

Name

Grade for 2024-25 school year

Gender

Male Female

Birthdate

School they will attend for 24-25 school year (the listed school are the schools we provide transportation from)

Bell Lindbergh Mitchell Other

If school is "other," which school will they attend and what is the transportation plan?

What are your student's strengths? What do they especially enjoy doing?

Does your student have any behavioral challenges, learning disabilities, etc?

Does the student have an IEP or 504 plan?

Yes No

If yes, please explain what the IEP is for and what accommodations are included in the IEP or 504 plan.

Please list any of the following: current medications, medication allergies, food allergies, or chronic health conditions.

Students must be toilet trained to participate in Resilient Kids.

Yes, the student is toilet trained. No, the student is not toilet trained.

Student's Address

Student lives with (choose all that apply)

Mother Father Grandma Grandpa Other relative(s) Other non-related adult(s) Foster parent(s)

Parent Information

Parent 1 Name

Are you the parent or legal guardian of this student?

Yes No

Parent 1 Primary Phone

Can we text information about the program to this number?

Yes Please use another number Please email

Parent 1 Email

This address will receive a confirmation email

Parent 1 Address (if different from student's)

Parent 2 Name

Parent 2 Primary Phone

Parent 2 Email

This address will receive a confirmation email

Parent 2 Address (if different from student's)

Emergency Contacts

Emergency Contact 1 Name

Emergency Contact 1 Phone

Emergency Contact 1 Relationship to Student

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 2 Relationship to Student

Transportation Information

My student will be transported to Resilient Kids from:

Bell Elementary School Lindbergh Elementary School Mitchell Elementary School I will transport them myself

Please list the names of anyone you authorize to pick up student. Parents/guardians and emergency contacts listed on this form may always pick-up students. Anyone picking up a student may be asked to show photo ID.

Please list the names of anyone who is NOT authorized by you to pick-up student.

Does your student have permission to walk home from the Rose Bowl? Note: if a student wishes to walk home early, director must make contact with student's parent.

Yes No

Releases and Late Policy

RELEASE OF LIABILITY: I, parent/guardian of the above-mentioned student, give my permission for him/her to participate in Resilient Kids and I release the One Hope staff and volunteers from liability in the case of any kind of injury or harm that could occur during or due to my child's participation. I authorize the One Hope staff and volunteers to give my child emergency medical care and to transport him/her to and from places where such care can be provided and to authorize such care as they deem necessary. I also give permission for my child to be transported to and from One Hope's programs including Resilient Kids and to and from events, activities, and field trips associated with One Hope, formal or informal. Further, I agree to abide by the policies of One Hope in relationship to Resilient Kids and other One Hope events and activities.

Do you consent to the above statement?

Yes, I understand and give my consent.

MEDIA RELEASE: I also give my consent for One Hope staff or persons given permission by One Hope staff to use photos, videos, stories, and/or audiotape that feature or include my child and to use work done by my child as well as my child"s first name for the purpose of publicizing and promoting One Hope Ministry. I understand that these images, text, or recordings maybe be published in newspapers, magazines, or on the internet, may be broadcast on television or radio, may be utilized in One Hope fund raising efforts and/or may be presented in One Hope information or promotional materials or presentations or used however One Hope sees fit.

Do you consent to the above media release?

Yes, I give my full consent to the above media release. I give consent for my student's photos and videos to be used ONLY INTERNALLY, such as printing photos to be hung in the classroom. I do not consent to their photo being shared on social media.

Late Pick-Up Policy

Students must be picked up from the Rose Bowl between 4:50-5:10 pm

We do not offer transportation after Resilient Kids.

ANY PARENT WHO WILL BE LATE MUST CALL.
We understand that unavoidable circumstances come up. Our goal is to support you and your child to the best of our ability. In the event that you will be late, we ask that you communicate with us as early as possible.

If no call was received prior to 4:30 p.m., the late fee will be assessed.

If a parent is late picking up their child a second time in a semester, regardless of a phone call, late fee charges will apply and must be paid within a one week period. If the fees are not paid, the child will be suspended until the fees are paid.

If a parent is late picking up their child a third time, in addition to the fee being charged, we will set a meeting with the parent/guardian to discuss how we can move forward.

Late Fee Schedule:

5:10-5:30 $10.00
5:30-5:45 $25.00

Do you agree to the late policy?

Yes No

Note: filling out this registration does not guarantee your student's participation in our Resilient Kids afterschool program. If their age group is full, your student will be placed on our waitlist.

Resilient Kids Program Registration

Description

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