MENU

Summer 2018 Leadership Institute Application

First Name
Middle Initial/Name
Last Name
Country
Address Line 1
City
State
Postal Code
can be found via The Source, or any report card or progress report
Most Recent SBAC scores
if applicable
Eligible for Free/ Reduced Lunch
See page 5 for required attachments.
Guardian Information
Additional Guardian Information
Emergency Contact Information

These people will be contacted in the case of an emergency and are authorized to pick up your child from the site location.

Country
Address Line 1
City
State
Postal Code
Country
Address Line 1
City
State
Postal Code
Pick Up Authorization Information

The following person(s) have permission to pick up my child from site, choice class and/or field trip locations.

My child has permission to walk or bike home from the site location
Medical Information
Country
Address Line 1
City
State
Postal Code
/
/

Please check any of the following statements that are true for your child, and fill in the corresponding information.

My child has been diagnosed with Attention Deficit Disorder.
My child has been diagnosed with Attention Deficit Hyperactivity Disorder
My child has been diagnosed with a mental health disorder
If "Yes" complete next field.
My child takes prescribed medicine daily
If "Yes" complete next field.
My child has been diagnosed with diabetes
My child has asthma (please be sure they keep an inhaler on-hand).
My child has known allergies
If "Yes" complete next two fields.
My child has been diagnosed with a learning disability
If "Yes" complete next field.
/
/
Country
Address Line 1
City
State
Postal Code
General Authorizations
Release of Medical/ Dental Treatment and Liability

In instances when needed, I hereby authorize and consent to the administration of all medical dental and surgical examination or operations and treatment or all other related care, including emergency transportation. I understand that Empowering Youth and Families, its volunteers or facilities and their officers and employees, assume no financial obligation or liability in case of my child’s accident, illness, and/or treatment. I assume full financial responsibility for emergency treatment for my child. EYFO carries no additional liability coverage for illness or accident for your child.

/
/
Field Trips and Outings
My child has permission to participate in and to attend field trips, including but not limited to visits to parks, the beach, overnight trips, shopping, movies, museums, water parks, neighborhood walks, libraries or other field trips as scheduled by means of walking, bus, personal vehicles or public transportation.
Release of Publication
My child may be photographed for EYFO’s publication.
Release and Indemnity Agreement

The foregoing information is complete and true to the best of my knowledge. I also confirm the authorizations and consent detailed within this document. I understand that should my child act in a manner that is unsafe for him/her self and/or others, s/he may be excluded from the program. I hereby release, discharge and covenant not to sue EYFO, its employees, volunteers, officers, agents and the facilities used for all liability to me or my child or my child’s personal representatives, assigned heirs and next of kin from any and all claims, demands, losses or damages on account of any injury or damage to property caused or arising from my child’s participation in the program.

/
/
Helpful information may include: strengths and weaknesses in an academic setting, ways to redirect them if off focus, subject matter we may incorporate to better engage them, etc.
Required Attachments
No file selected
No file selected
No file selected