A Different World: All-Girls College Sleepover

Participant Name

First

Last

Participant Date of Birth

Name of School

Participant Student ID #

Participant Grade Level

Does the participant receive free or reduced price lunch?

Participant Gender

Male

Female

Refuse

Participant Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Participant Race

Food allergies or intolerances

Which test(s) have you already taken?

SAT

ACT

CLT

None

Have you completed the FASFA?

Parent/Guardian Name

First

Last

Parent Email

Parent Phone

Parent Address

City

State/Province

Zip/Postal

Country

Household Income

Total Number of people living in the household

REGISTRATION DATA IS USED FOR THE PURPOSES OF MAINTAINING FUNDING TO PROVIDE THIS FREE PROGRAM

Liability Waiver for Minor Participants at The Skills Center

I, the undersigned parent/guardian, hereby state that my child(ren) will only be picked up by authorized persons listed on the authorized pick-up form when arriving at and leaving The Skills Center. I understand and agree that The Skills Center is responsible for my child only while they are within the premises of the facility. Once my child leaves the premises with an authorized person, The Skills Center is no longer liable for their safety and well-being.

Will your child walk to The Skills Center?

Liability Waiver for Minor Participants Walking to and from The Skills Center

I, the undersigned parent/guardian, hereby give permission for my child(ren) to walk to and from The Skills Center. I understand and agree that The Skills Center is only responsible for my child while they are within the premises of the facility. Once my child leaves the premises, The Skills Center is no longer liable for their safety and well-being.

PERMISSION WAIVER

I give my child permission to participate in The Skills Center Collaborative’s programs. I understand that my child will participate in in-person, virtual and/or online self- pace programming. Your child is expected to complete surveys and participate in focus groups around how to better provide services to youth people and the type of program/services of their interest.

I give permission for my child to participate in The Skills Center Collaborative's program.

As part of the registration & enrollment process, The Skills Center collects personal and household demographic information. This information is used by The Skills Center for the purpose of providing requested services and may also be used to contact participants from time to time with information that relates to their requests or interests. Your information will never be shared with third parties without prior written consent. The Skills Center Programs are generously funded by the Children's Board of Hillsborough County (CBHC), United Way and other funders, and as part of our agreement, we are required to share the information provided on this form as well as ongoing participation information including attendance, program survey responses and the results of questionnaires and observations, for evaluation and quality assurance purposes. The Skills Center does not collect personally identifiable information from individuals unless they provide it voluntarily and knowingly. Your consent to share this information will remain valid from today’s date until service completion and may be revoked at any time by informing a The Skills Center staff member. Please indicate below whether you consent to the sharing of this information with CBHC, The United Way and other program funders. Your decision will not impact your ability to participate in services at The Skills Center. I give permission to The Skills Center Collaborative to share my family and student information with The Children's Board of Hillsborough County, The United Way, and other funders of The Skills Center. *

I give permission for my child to participate in The Skills Center Collaborative's program.

COVID-19, INJURY, SICKNESS LOSS OR DAMAGE, BEHAVIOR

I understand that even when every reasonable precaution is taken, accidents can sometimes still happen. I understand the risk to my child participating in sports in the age of COVID- 19 and take full responsibility to ensure that he/she adheres to the CDC’s safety guidelines on communicable diseases as well as the rules and regulations at The Skills Center. I understand and expressly acknowledge that I release THE SKILLS CENTER, INC., CDC OF TAMPA, G3 LIFE APPLICATIONS, MEN OF VISION AND GIRLS EMPOWERED MENTALLY FOR SUCCESS as well as all other partners, and their staff members from all liability for any injury, sickness, loss or damage connected in any way whatsoever to participation in THE SKILLS CENTER program activities. I understand that at the discretion of Trainer, Coach and/or staff my child may be dismissed from a session, for inappropriate behavior or displaying symptoms of Covid 19. *

I understand and give permission.

PHOTO RELEASE

I give permission to use, reprint, and produce any photographs or videos taken of me or my child and written materials supplied by me or my child in the form of evaluations during the sessions. I understand that such material will be used to promote the programs and organization. *

I give permission to The Skills Center to take photos and/or videos of my child.

I DO NOT give permission to The Skills Center to take photos and/or videos of my child and I understand that It is my child’s responsibility to remove themselves from any photo/video opportunities.

EDUCATION DATA

As part of this program, we plan to assess and support your child’s academic success and would like permission to gather the following data when needed during the program about your child from Hillsborough County Public Schools or their charter/private school. We are requesting access to one or more of the following records: report card, progress report, test score, GPA, behavioral, attendance, and/or IEP. Federal Law (FERPA) requires us to keep educational information about your child private. We will keep your child’s records private by not sharing with anyone outside of our programs, locking/password protected files in file cabinets when not in use. We will only use the educational data for the purposes explained and we will not save any individually identifiable educational data about your child. *

I consent to release my child’s data as stated above.

LIABILITY RELEASE

I understand that even when every reasonable precaution is taken, accidents can sometimes still happen. I understand the risk to my child participating in programs in the age of COVID- 19 and take full responsibility to ensuring that he/she adheres to the CDC’s safety guidelines on communicable diseases as well as the rules and regulations at The Skills Center. I understand and expressly acknowledge that I release The SKILLS CENTER, INC., as well as all other partners, and their staff members from all liability for any injury, sickness, loss or damage connected in any way whatsoever to participation in The SKILLS CENTER COLLABORATIVE’S program activities whether on or off the program and partners’ premises. I understand that at the discretion of program supervisor and/or staff my child may be dismissed from the program, for inappropriate behavior and displaying symptoms of Covid-19 or other communicable diseases.

HEALTH HISTORY

The health history provided is correct so far as I know, and my son/daughter has permission to engage in all prescribed activities, except as noted by me. My son/daughter is in good health.*

My son/daughter is in good health.

If your child must take medication, it is preferred that medication be given to your child before attending.

EMERGENCY TREATMENT

I understand that if a medical emergency occurs, The Skills Center and/or its partners will contact me first, then the emergency contact person designated. If necessary, I authorize The Skills Center to arrange immediate medical treatment for my child’s health and safety. I will be financially responsible for all charges and fees incurred in the rendering of said treatment.*

I understand

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