Summer Leadership Institute Application : Programs : Empowering Youth and Families

Summer Leadership Institute Application

Full Name

First Name *

Middle *

Last Name *

Preferred/Nickname

Age

Grade

Ethnic Background(s)

Gender

Home Address

Country

Address Line 1

City

State/Province

Postal Code

School/ District

Student ID

can be found via The Source, or any report card or progress report

Most Recent SBAC scores

Math

ELA

Most Recent Star Reading Assessment Score

if applicable

Eligible for Free/ Reduced Lunch

See page 5 for required attachments.

Guardian Information

Guardian’s Name

Relationship

Preferred Phone

Employer

Position

Additional Guardian Information

Guardian’s Name

Relationship

Preferred Phone

Employer

Position

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.

Contact’s Name

Relationship

Preferred Phone

Address

Country

Address Line 1

City

State/Province

Postal Code

Contact’s Name

Relationship

Preferred Phone

Address

Country

Address Line 1

City

State/Province

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.

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

My child has permission to walk or bike home from the site location

Medical Information

Applicant’s Name

Physician’s Office

Physician’s Name

Physician’s Phone

Physician’s Address

Country

Address Line 1

City

State/Province

Postal Code

Preferred Hospital

Date of Last Physical Exam

Month

Day

Year

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.

Mental Health Disorder

My child takes prescribed medicine daily

If "Yes" complete next field.

Daily Medicine

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.

Known allergies

Allergy treatment

My child has been diagnosed with a learning disability

If "Yes" complete next field.

Diagnosed learning disbility

My child has another illness or medical issue, not listed above

Dentist’s Office

Dentist’s Name

Dentist’s Phone

Last Dental Exam

Month

Day

Year

Dentist’s Address

Country

Address Line 1

City

State/Province

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.

Guardian Signature

Date

Month

Day

Year

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.

Initial (for Yes)

Release of Publication

My child may be photographed for EYFO’s publication.

Initial (for Yes)

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.

Guardian Signature

Date

Month

Day

Year

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Is there anything you’d like to share about your child to better help us interact with them? If so, please do so here.

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

A recent writing sample (at least 2 handwritten paragraphs produced by the applicant).

No file selected

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A recent report card (from the school year).

No file selected

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A copy of your IEP or 504 plans (if applicable).

No file selected

Click or drag here to add files

Programs

Events

Fundraisers and events help us raise awareness and generate crucial resources to serve our community. Join us at our next event and see how you can get involved.
Find out more.

Empowering Youth and Families Outreach students in the College and Career Readiness Program on our annual college and experiential tour at Bowie State University in Maryland.