Caminos Enrollment Forms:We are so happy you are going to be a part of Caminos: College and Career Pathways program! Please complete the following forms to finish your enrollment process. If you have any other questions about enrolling, please reach out to Eva Farrell, our Recruitment and Enrollment Manager at eva@hydesquare.org.Release of School Records for Participant: (Parent/Guardian if participant is under the age of 18)As a part of Caminos, you will receive free educational support. To help us with this, we ask that you share access to your grades, so we can support you academically. For participants who are in high school, we will review grades twice per quarter. For participants who are attending a college, university, or other post-secondary program, we will request evidence of academic progress (such as unofficial transcripts or mid-term grades) approximately twice per semester. The Release Information is below. I give my consent and authorization for the release of my school and classroom records to the staff of Hyde Square Task Force (HSTF). If HSTF is unable to obtain these records directly from my school, I agree to provide them upon request. I understand that all information and records will be kept confidential and used only for academic coordination and assistance. The records being requested include, but are not limited to Attendance Records, Report cards and Progress Reports, Class schedules, Standardized Test Scores, Individual Education Plans and/or 504 Plans (if applicable).* You have my consent You do not have my consent Participant Signature:*Parent/Guardian Signature:Please use this space to inform us of any learning, emotional, and/or behavioral support needs that our staff should be aware of.Do you have an IEP?*IEP stands for Individualized Education Program. The purpose of an IEP is to lay out the special education instruction, supports, and services a student needs to thrive in school. IEPs are part of PreK–12 public education.NoYesUnknownDecline to AnswerDo you have a 504 plan?*504 plans are formal plans that schools develop to give kids with disabilities the support they need. 504 plans often include accommodations. Accommodations don’t change what kids learn, just how they learn it. The goal is to remove barriers and give kids access to learning.NoYesUnknownDecline to AnswerWhat is the highest level of education earned by either one of your parent(s) or guardian(s)? (Answer this question for the person who has the highest level of education only).*Associate's DegreeCollege or BeyondGEDHigh SchoolMiddle SchoolUnknownContact Information: (Parent/Guardian)We will use this contact information in case we cannot get a hold of you or for any unforeseen emergencies. Contact 1 Name:* First Last Contact 1 Relationship to Participant:*Contact 1 Primary Phone Number:*Contact 2 Name: First Last Contact 2 Relationship to Participant:Contact 2 Primary Phone Number:Medical Information:This section of the enrollment form will ask you to fill out information regarding medical conditions or other important medical information for yourself. This information can be used to provide you with resources or to support you in the case of an emergency. Are there any medical conditions you want us to be aware of:Do you have any allergies you would like to make us aware of?Are there any accommodations you will need to participate fully in the Caminos program?*YesNoIf you selected "yes," please explain below:Are there any self-administered medications you want to make us aware of in case of any emergency?For example: EpiPen, Inhaler, Insulin, etc. Do you have health insurance?*YesNoProvide your health insurance provider:*Provide the name of the policyholder:*Provide the policy number:*ConsentsHere are HSTF's Medical, Photo/ Video, and Liability forms. Select an option below for each. The signature and date at the end will sign all three forms.Medical Consent:*I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take myself, or my child, to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my, or my child's health. You have my consent You DO NOT have my consent Release and Waiver of Liability Agreement for Participation:* You have my consentThis agreement is by and between Hyde Square Task Force (herein referred to as HSTF) and the individual whose name is signed and printed below (herein referred to as participant). 1. I am participating in the Caminos program at HSTF, during which I may participate in physical activity workshops. I recognize that participation in such activities requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Caminos Program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Caminos Program. 3. In consideration of being permitted to participate in the Caminos Program, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Caminos Program, I knowingly, voluntarily and expressly waive any claim I may have against HSTF and its employees, board members, officers, volunteers, and staff for damages, and injury, including death, that I may sustain as a result of participating in the Caminos Program. 5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue HSTF and its employees, board members, officers, volunteers, and staff for any injury or death caused by my voluntary participation in the Caminos Program. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as I participate in the Caminos Program.Participant Signature:*Parent/ Guardian Signature: (only if participant is under the age of 18)Date:* MM slash DD slash YYYY What is your t-shirt size (adult sizes)?*XSSMLXLXXLXXXL Δ
