JEA Enrollment Form Jóvenes en Acción Enrollment Forms:We are so happy you are going to be a part of Jóvenes en Acción (JEA)! Please complete the following forms to finish your enrollment process. Here are a few things to note: Each heading indicates whether the section should be completed by participant, parent/guardian, or both. 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 and Parent/Guardian)As a part of JEA, 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. 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. 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 school consent You DO NOT have my school consent Participant Signature:*Parent/Guardian Signature:*Participant Name:* First Last School:*Academy of the Pacific RimAnother Course to CollegeBoston Adult Technical AcademyBoston Arts AcademyBoston CollegiateBoston Community Leadership AcademyBoston Day & Evening AcademyBoston Green AcademyBoston International SchoolBoston Latin AcademyBoston Latin SchoolBoston PreparatoryBoston Teachers Union K-8 SchoolBoston Trinity AcademyBrighton HighBrooke 8th Grade AcademyBrooke HighBurke HighCharlestown High SchoolCity on a HillCity on a Hill (Dudley)Codman AcademyCommunity Academy of Science & HealthConservatory LabCristo Rey BostonCurley K-8Dearborn STEM AcademyEast Boston HighEdison K-8Edward M. Kennedy Academy for Health CareersEnglish HighExcel AcademyExcel HighFenway HighGreater Egleston High SchoolHenderson K-12 InclusionHennigan K-8Hernandez K-8Irving MiddleJoseph LeeMadison ParkMargarita Muniz AcademyMATCH HighMATCH MiddleMcCormack MiddleMelvin King South End AcademyMeridian AcademyMETCOMission Hill K-8Murphy K-8Newcomers AcademyNew Mission HighO'BryantOtherQuincy Upper SchoolRoxbury PreparatorySnowden InternationalTecca Online SchoolTechBoston AcademyTobin K-8UP Academy DorchesterYoung Achievers Science & Math K-8Current Grade:*8th9th10th11th12th7th6th5th4th3rd2nd1stOtherHS GradReport Card/ Progress Report Upload:*Please upload a recent report card or progress report for education staff to have a baseline of where you are academically. Accepted file types: jpg, png, pdf, jpeg, Max. file size: 256 MB.Please use this space to inform us of any learning, emotional, and/or behavioral support needs that our staff should be aware of.Does your child 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 AnswerDoes your child 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)? (Answer this question for the parent who has the highest level of education only).*Associate's DegreeCollege or BeyondGEDHigh SchoolMiddle SchoolUnknownEmergency Contact Information: (Parent/Guardian)Parent/Guardians we received your contact information on your child's application, you will be our first contact. This section is in case we can't get a hold of you, who is another emergency contact we can call for your child.Emergency Contact 2 Name:* First Last Emergency Contact 2 Relationship to Youth:*Emergency Contact 2 Primary Phone Number:*Medical Information (Parent/Guardian):This section of the JEA enrollment form will ask you to fill out information regarding medical conditions or other important medical information for your child. This information can be used to provide your child with resources or to support in the case of an emergency. Please select any of the following medical conditions your child has: Asthma Diabetes ADHD Seizures Anxiety/Depression Mental Health Diagnosis - If your child has a particular diagnosis please detail it in the question below. Other None Prefer not to answer If you selected "other or Mental Health Diagnosis" to the question above, please provide details below:Does your child use any of the following?*If your child uses more than one, hold down the shift key to pick multiple options:InhalerEpipenInsulinSelf-administered medicationOtherNoneIf you selected "self-administered medication or other", please list below:Does your child have any allergies?*YesNoPrefer not to answerIf you selected "yes" to the question above, please list them below:Are you concerned about a medical condition that will potentially prohibit your child's participation at HSTF?*YesNoIf you selected "yes," please explain below.Does your child have health insurance?*YesNoPlease fill in below your health insurance provider:*Please fill in below the name of the policyholder:*Please fill in below the policy number:*ConsentsHere are HSTF's Medical 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 my child to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my child's health. You have my consent You DO NOT have my consent Release and Waiver of Liability Agreement for Participation:* I hereby agree to the following:This agreement is by and between Hyde Square Task Force and the individual whose name is signed and printed below (herein referred to as participant). I hereby agree to the following: 1. I am participating in the Jóvenes en Acción Program at Hyde Square Task Force, during which I will 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 Jóvenes en Acción Program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the Jóvenes en Acción Program. 3. In consideration of being permitted to participate in the Jóvenes en Acción Program, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Jóvenes en Acción Program, I knowingly, voluntarily and expressly waive any claim I may have against Hyde Square Task Force 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 Jóvenes en Acción Program. 5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue Hyde Square Task Force and its employees, board members, officers, volunteers, and staff for any injury or death caused by my voluntary participation in the Jóvenes en Acción 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 Jóvenes en Acción Program. Participant Signature:*Parent Signature:*Date:* MM slash DD slash YYYY What is your t-shirt size (adult sizes)?*XSSMLXLXXLXXXL Δ
