2023-2024 Completely KIDS Program Information and Registration

RELEASE OF LIABILITY AND CONSENT TO PARTICIPATION

Please read before continuing to registration form.

Participation in All Activities
I give permission for my child(ren) to participate in all the program activities including but not limited to: academic assistance and recreational programs, off-site events and/or field trips, transportation to and from all events whether private or agency provided, all programs which Completely KIDS℠ deems vital to the safety, academic and personal life skill development of my child.

Consistent Attendance & Appropriate Behavior
I understand that my child(ren)’s participation in Completely KIDS is voluntary and his/her success depends on consistent attendance and adherence to behavior guidelines, as set forth in the Parent and Student Handbook, a copy of which I have received. I understand that my child may be removed for attendance or behavior issues.

Surveys
I understand my child(ren) may be surveyed from time to time about his/her feelings and experiences in the program and his/her life experience.

Release of Records
I understand my child(ren)’s student records will be requested for the purpose of providing educational support, assistance, progress and improvement to evaluate the impact of the program and to obtain continued program funding.

Injury or Loss of Property
I understand the inherent risk of injury or loss of property associated with participation in this program and release Completely KIDS and the Omaha Public School District and all program partner agencies and their employees from any claims made by or on behalf of my child or family.

Medical Information and Emergencies
I give Completely KIDS and its representatives permission to secure treatment in the event of an emergency resulting from illness or injury. I understand that if a medical emergency arises, the program staff will take all steps necessary to ensure the safety of my child(ren) and will call a public emergency vehicle for transport to the nearest emergency facility if necessary. I also understand that I am responsible for any transportation charges and medical expense incurred.

I understand it is my responsibility to notify the Program Coordinator of any specific medical needs of my child(ren). It is also my responsibility to inform the Program Coordinator of all medications that my child(ren) may be taking and provide the medication. I understand my child(ren) will be responsible for administering his/her own medication at program. The Program Coordinator has no responsibility in administering medication, except in the event of an emergency when the parent has authorized the Program Coordinator to do so and trained the Coordinator and one additional staff person on how to administer the medication. Over-the-counter medication will not be distributed by program staff.

Publication Consent
From time to time, Completely KIDS, and approved partners, may take photographs, recordings (video and audio) and written statements of the participants and families in our programs. We may use these images and testimonials in our agency marketing materials to include, but not be limited to: website and social media publication, annual reports, brochures, direct mail campaigns, billboards and other marketing materials. We may also create video or other recordings for educational or other promotional use. If you do not wish for your child(ren) to be photographed, please indicate as such on the registration form. Otherwise, you hereby grant to Completely KIDS, and approved partners, the full and exclusive right to photograph and/or record (video and audio) any or all of your child(ren)’s statements, actions, performances or attendance at programs or events conducted or sponsored by Completely KIDS, to reproduce such photographs and recordings or any part of them by any method, and to distribute, publish or display such photographs and recordings, or license others to do so. In so doing, the undersigned waives any and all rights which he or she may have to be compensated for said photographs or recordings as well as waives any claims and demands which he or she may otherwise have in regard to such use.

Program Registration Form

Please complete one form per child.

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    Student Information

    Gender*
    Participation*
    Do you need AM, PM, or Both. Does your child have access to an electronic device (tablet, computer, etc.)?* Does your child have internet access?*
    School Lunch (select an option)* Ethnicity (select an option)* Race (select primary)* My child has permission to walk home, and I understand Completely KIDS is not responsible for my child after he/she has left program. - Copy* My child takes the bus.* My child takes medication.* Are there any restraining or custody orders involving your child that we need to be aware of? * The following emergency contacts ARE authorized to pick up my child.
    Add a second emergency contact?

    My Child’s Medical Information

    Completely KIDS will arrange for emergency medical care if necessary.

    Parent/Guardian Information

    Relationship to Child*
    Gender*
    I am the sole parent/guardian.* If no, please fill out Additional Parent/Guardian Information section.

    Additional Parent/Guardian Information

    Relationship to Child*
    Gender*
    Please list any other information we should know.

    The following information is for reporting purposes only.

    Number in Family (select an option)* Household Type (select an option)*
    Estimated Annual Family Income (select an option)* Other Services Currently Received (select all that apply)

    Documentation & Authorization Release