Scholar Application SDC

Scholar Application Summer Day Camp 2018
Confidential Form

4120 Gentry Drive Dallas, Texas 75212 214.631.7027 info@voiceofhope.org

Please complete one form for each child.

Any confidential information requested is for our records and will only be used on "at needed" basis. The answers you provide will otherwise be kept completely confidential. Your cooperation in providing this information is both appreciated and necessary.
Starred items are required to be completed

Youth Information

* Indicates required field

Child's Name *

Date of Birth Month/Day/Year *

Gender *

Primary Parent/Guardian

Name *

Date of Birth month/day/year *

Home Phone *

Cell Phone *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Employer *

Job Title *

Work Phone *

Custodial Parent Yes/No *

Parent/Guardian

Name *

Date of Birth *

Home Phone *

Cell Phone *

Emergency Contact Information/Authorized Pick-Up (Other than parent or guardian) Required

Name *

Phone Number *

Driver's License Number *

Street Address, City, ST, Zip *

Name *

Phone Number *

Driver's License Number *

Street Address, City, ST, Zip *

Name *

Phone *

Driver's License Number *

Street Address, City, ST, Zip *

My child has permission to be released into the care of an Authorized pick Up Person who is a sibling under the age of 18 *

Yes No

Medical Release Information

Student's Full Name *

Health History

All medications must include a medication form on file, be prescribed by a doctor and delivered to the After-school Program in its original bottle. We do not administer over the counter medications. Rescue Medications can be carried by the participant with the prescribing doctor's written permission.

Authorization for Medical Treatment

In the event that I cannot be reached to make arrangements for medical treatment, I authorize Voice of Hope staff to administer first aid or transport to the nearest hospital or emergency care facility.

Name of licensed Physician *

Physician's Phone Number *

Physician's Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Preferred Hospital *

Hospital Phone Number *

Hospital Address *

Line 1

Line 2

City

State

Zip Code

Country

By typing in your name below you are certifying that the information is correct and accurate and that you agree to the medical treatment statements *

Date *

I certify that

Name of child *

has been examined by a licensed physician in the past 12 months, is fully immunized and able to participate in the After-school program. The health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities, field trips, except as noted by the examining physician and me.

By typing my name here I am signing in agreement to the above *

Date *

Family Church Information

Church Name *

Pastor's Name *

Church Number *

Church Address *

Line 1

Line 2

City

State

Zip Code

Country

Additional Information

My child can receive free/reduced lunches *

VOH may release my child to the non-custodial parent *

Your Family Type *

How did you hear about Voice of Hope *

Annual Household Income *

Your Family Setting *

Number of people in your household *

Consent

Initial in the box below all where you are consenting

I give my permission for my child to view a Voice of Hope approved G rated movie, even though it may not be part of regularly scheduled lesson plans.

Movies - Initial Consent Below *

I have received and read a copy of the Voice of Hope Parent Handbook and understand all policies and procedures therein.

Parent Handbook - Initial Below *

I give permission for my child to be transported and supervised by Voice of Hope employees for emergency care and field trips.

Transportation - Initial Consent Below *

I give permission for my child to participate in Voice of Hope field trips (Summer Day Camp)

Field Trips - Initial Consent Below *

I give my permission for my child to participate in water activities, including sprinkler play, splash or wading pools and water table play.

Water Play - Initial Consent Below *

Please add any additional comments here *

I understand that that my child will be served a PM meal that meets USDA requirements in the ASPIRE after-school program.

Program Meals - Initial consent Below *

I understand that my child will be served a lunch meal and PM snack in the Summer Day Camp program.

Summer Day Camp Meals - Initial consent Below *

I certify that my child's current immunizations records and TB test (if applicable) can be located at the school my child is currently attending.

Immunizations and Screenings - Initial Below *

Name and Contact Number of School *

I understand that I will be charged an additional $1.00 per minute I am late after close of site 6:30 PM (per child). I also understand that I must pay the late fee before my child(children) can return to the program.

Late Fee - Initial Consent Below *

I understand that it is my responsibility to provide documentation of all custody issues.

Custody - Initial consent Below *

Voice of Hope is granted permission to use any individual or group photograph and/or videotape showing my child (children) in Voice of Hope activities for use in public relations, promotional or advertising purposes.

Photo Release - Initial Consent Below *

I agree to let Voice of Hope collect academic grade information from my child''s report card for the purpose of program measurement.

Grade Collection -Initial consent Below *

I understand that it is my responsibility to notify Voice of Hope staff by 8:00 AM daily if my child will not attend the program that day. I understand that I must call the designated Voice of Hope site phone.

Absences - Initial Consent Below *

I understand that Voice of Hope will be closed on select holidays and care may be available at an additional cost.

Program closures - Initial consent below *

I acknowledge that I am the responsible party for all children listed on the application. By acknowledging this, I am responsible for all Summer Day Camp and/or ASPIRE After-school program fees, late fees, and any behavior issues that may occur.

I am the responsible party - Initial below *

My child has permission to participate in activities with voice of Hope Ministries, Inc. I give permission for him/her to ride in the vehicles to be used for transportation as a participant in Voice of Hope Ministries, Inc. programs and activities. I give permission to Voice of Hope and a third party to use photographs or video images of myself and/or my child (children).

I authorize Voice of Hope Ministries, Inc. staff and volunteers to consent to emergency medical treatment for my child if I cannot be contacted.

I hereby relieve and release the ministry, its directors, officers, employees, and volunteers and all persons assisting in the activities, from any and all liability from an accident or injury of my child while participating in program activities. I agree to indemnify all of the parties described above from all claims made by or asserted on behalf of my child.

As the custodial parent, by typing my name below I consent to the release and permission statement I read, understood and acknowledge above *

Date *

Disciplinary Action System

ATTENTION parents and students: Please read carefully!
Parents will be required to acknowledge understanding and agreement with the disciplinary system of Voice of Hope Ministries, Inc.

Warning System:
Verbal warning issued.

Written Warning – Program Manager/Site Leader informed
Written Warning – Program Manager/Site Leader contacts parent or guardian
Written Warning – The Director of Programs is informed and schedules a conference with the parents and the coach.

Suspension:
If your child receives 3 written warnings, a Parent Conference will be scheduled to inform you of the suspension and the reasons. The conference must include youth, program associate, parent, Program Manager and the Director of Programs. If the parent refuses to have a conference within 3 days of the occurrence, the child will be suspended for 2 days.
NOTE: Fighting and/or cursing will result in an automatic suspension.

Dismissal
If a child is suspended two times, the child will be dismissed for the rest of the Semester.

Outings or Trips
If a child is suspended, they will not be allowed to go on any trips or outings scheduled during that Semester.

The Director of Programs will consult with the President/CEO before anyone is dismissed. Before a child is dismissed, the Program Manager/Site Leader and Director of Programs must have a Parent Conference. The outcome of the Parent Conference will be documented and placed in the child’s folder.

I have read and understand the Disciplinary Action System of Voice of Hope and agree to abide with the mandates found within. I further state that I have or will speak to my child regarding this system to ensure compliance. I know discipline is necessary both for the welfare of each student and for Voice of Hope. I will support the disciplinary procedures of Voice of Hope.

Disciplinary Action System Acknowledgement and Agreement *

Date *

Parent and Student Commitment

Thank you for choosing Voice of Hope’s ASPIRE and/or Summer Day Camp program for your child. It is our commitment to provide a high quality after-school and out-of-school experience for your child that is enriching, both academically and spiritually.
In an attempt to insure that both you as parent and us as staff are aligned with the care and support for your child we are establishing a covenant between us, Voice of Hope Ministries, Inc. and you, the parent/guardian.

As a Parent/Guardian, I commit to:

Pray for my child(ren) daily.
Pray for Voice of Hope and the VOH coaches daily as they minister to my child spiritually and academically.
Communicate with VOH the spiritual and/or academic improvements of my child as a result of attending the program.
Insure my child attends the VOH ASPIRE program a minimum of 3 times per week.
Allow my child to participate in the program until 5:30 pm or later, in order to get the full benefit of the academic and spiritual enrichment program.
Share major achievements as well as any potential concerns in academics or behavior with VOH staff.
Communicate immediately with VOH if there are changes in address or phone number.
Attend at least 3 parent meetings each semester.
Work with VOH staff on discipline issues that occur within the program.
Make timely payments for all fees.
Consistently sign my child in and out of the program.

Commitment - By typing my name I commit to the above *

Date *

Commitment - By typing my name I commit to the above *

Date *

As a Student, I commit to:

Have fun while learning.
Participate in all programs and activities.
Take care of all Voice of Hope property and equipment.
Keep my hands and feet to myself.
Be courteous and respectful in my behavior and speech.
Follow the directions of all staff.
Talk to my parents about my day at VOH.
Make friends with other participants.
Practice my weekly Bible verse with my parents.

Commitment - By typing my name I commit to the above statements *

Date *

Household and Income

Check all that apply to you *

Single Parent household, (currently working and/or in job training or an educational program for a minimum of 25 total combined hours a week or more)? Two-Parent household, (who are BOTH currently working and/or in job training or an educational program for a minimum of 50 total combined hours a week or more)?

# of people in your family? *

Based on the number of people in your family, do you fall under the following income guidelines? *

Submit

Scholar Application Summer Day Camp 2018
Confidential Form

Please complete one form for each child.

Youth Information

Primary Parent/Guardian

Parent/Guardian

Emergency Contact Information/Authorized Pick-Up (Other than parent or guardian) Required

Medical Release Information

Authorization for Medical Treatment

Family Church Information

Additional Information

Consent

Disciplinary Action System

Parent and Student Commitment

Household and Income

We Would Love to Have You Visit Soon!

4120 Gentry Drive Dallas, Texas 75212

Office Hours

Telephone

Email

Scholar Application Summer Day Camp 2018​Confidential Form

Please complete one form for each child.

Youth Information

Primary Parent/Guardian

Parent/Guardian

Emergency Contact Information/Authorized Pick-Up (Other than parent or guardian) Required

Medical Release Information

Authorization for Medical Treatment

Family Church Information

Additional Information

Consent

Disciplinary Action System

Parent and Student Commitment

Household and Income

We Would Love to Have You Visit Soon!​4120 Gentry Drive Dallas, Texas 75212

Office Hours

Telephone

Email

Scholar Application Summer Day Camp 2018
Confidential Form

We Would Love to Have You Visit Soon!

4120 Gentry Drive Dallas, Texas 75212