EmailMe Form - Big Ideas Summer 2021 Application

STUDENT INFORMATION

Please ensure all information entered is accurate and current.

Student Name *

First Middle Last

A separate application must be completed for each student.

School Site *

Student ID Number *

Your student's Identification Number can be found on his/her report card. Please also ask your student this is their school lunch number.

(If you do not know your child's ID#, please type 999-9999)

Current 2020-21 school year grade level *

Student Race / National Origin *

Child Ethnicity *

Gender *

Male

Female

Date of Birth *

MM / DD / YYYY

Does your student receive free or reduced lunch? *

Yes

No

Is the Student Proficient in English? *

Yes

No

Other Lanaguage(s) spoken in your home

Spanish

Haitian Creole

Other

Check all that applies

Does child have health insurance? (ex., private insurance, KidCare, Medicaid) 0 Yes 0 No
(If not, we may be able to help you find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.) *

Yes

No

Single Parent Household *

Female lead single parent household.
Male lead single parent household

Student Home Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Does the student have a documented disability? *

Yes

No

If YES, you MUST provide supporting documentation and complete the next three questions.
If No, Please proceed to Parent/Guardian Information.

If yes, do you have

an Individualized Education Plan (IEP) from the school system

a Section 504 Plan

a medical diagnosis from a doctor

Other

Check all that applies

Upload Supporting Documentation

If you answered yes to the above, how would you best classify the type(s)?

PARENT/LEGAL GUARDIAN INFORMATION

Parent/Guardian Full Name *

First Last

Does the child live with a legal guardian other than mother or father? *

Yes

No

If Parent/Guardian address is the same as student address please leave blank.

Street Address City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Email Address *

Phone *

### - ### - ####

Is the phone number above a cell/mobile phone?

Yes

No

Cell Phone Carrier *

Sprint

T-Mobile

Metro PCS

AT&T

Verizon

Boost Mobile

Cricket

Other

This is how you will receive updates and notifications via text messaging.
If your carrier is not listed, please click other and your site supervisor will add your carrier's name at a later date.

EMERGENCY CONTACT INFORMATION

YOU MUST COMPLETE A MINIMUM OF TWO EMERGENCY CONTACT. PLEASE ENSURE INFORMATION PROVIDED IS CURRENT and ACCURATE.

1. FULL NAME *

First Last

Phone *

### - ### - ####

Relationship to Student *

1st emergency contact address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Is above person to be contacted in an emergency? *

Yes

No

Emergency contact will be notified for any reason the primary contact does not respond.

Is above person authorized to pick-up child? *

Yes

No

2nd Emergency contact persons' FULL NAME *

First Last

Phone *

### - ### - ####

Relationship to Student *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Is above person authorized to pick-up child? *

Yes

No

Is above person to be contacted in an emergency? *

Yes

No

Emergency contact will be notified for any reason the primary contact does not respond.

HEALTH INFORMATION

All health conditions including allergies MUST be disclosed to ensure student safety.

Are there any medical conditions or behavioral problems? *

Yes

No

If yes please explain

Does your child have any allergies (food, hay fever, Peanuts, etc.)? *

Yes

No

If yes please list allergies

Are there any activities the child may not participate in? *

Yes

No

If yes please list activities

HELP US GET TO KNOW YOUR CHILD

We want to get to know your child better so we can provide the best possible experience in our programs.

What are the main ways we in which your child communicates? (Mark all that apply) *

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing,pulling,smiling,frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

What,if any, help does your child receive at this time? (Mark all that apply) *

What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *

If you marked "None of the Above" on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below.

Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do?

Yes

No

To support your child's successful participation in this program, in what areas might s/he need extra assistance?

No Specific help needed

Holding a crayon/pencil, writing, using scissors or other fine motor tasks

Managing feelings and behavior

Academic, Learning or reading activities

Adapting activities to take into account a visual or hearing impairment

Using assistive device(s) like a wheelchair, crutches, brace or walker

Personal services like help with feeding , toileting or changing clothes

Other

Please tell us anything else you think it is important for us to know about your child.

Explain

ONSITE CONSENTS AND DISCLOSURES

Consent to Medical and/or Surgical Treatment & Assumption of Risk and Release. In the event of injury to or illness of their son/daughter/ward, the undersigned hereby authorizes Big Ideas Educational Services, Inc. or representative thereof, to admit the registrant named to a facility for emergency medical treatment as may be deemed necessary to his or her health welfare. The undersigned hereby consents to whatever medical treatment is deemed necessary. The undersigned on his or her behalf of the registrant, their heirs, assigns and personal representatives, hereby releases Big Ideas, its commissioners, staff and employees from any and all claims arising out of the admission to, or treatment administered by, such facility. The undersigned hereby acknowledges and agrees that participation in the academic program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Big Ideas, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the academic program. Consent to Medical and/or Surgical Treatment & Assumption of Risk and Release. *

I agree

I disagree

I hereby authorize Big Ideas, and the members of its staff to take such photographs, television recordings and/or live television transmission of the registrant in whole, or in part, as they or members of the staff may wish, and to use and publish the same in such places and publications as Big Ideas, or its staff in its sole discretion consider to be of benefit to said parties. I hereby waive any right that I may have to inspect and/or approve the finished product that may be used here under or the specific use to which it may be applied. *

I agree

I disagree

I hereby authorize Big Ideas, to transport registrant on approved fieldtrips and outings. I understand that Big Ideas will use insured transportation companies to transport my child. The undersigned hereby acknowledges and agrees that participation in the summer camp program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Big Ideas, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the program. *

I agree

I disagree

I hereby authorize my child to walk to and from the program site. I understand that my child must enter the building and immediately go to the program area upon arrival. At dismissal, my child must exit and leave the grounds immediately, and not loiter in the building or in the bus loading area. The program reserves the right to revoke permission to walk at any time for actions deemed inappropriate. *

I agree

I disagree

If you agree, an additional release form will be provided. This form MUST be completed and notarized before services start.

I understand that to ensure all COVID-19 related safety procedures and onsite safety related dismissal procedures remain in place (i.e. ID checks and walker forms) dismissal will be decreased to our Procare curbside only. Authorized parents/guardians will remain in their vehicle, a Big Ideas staff member will identify authorized parent/guardian from a safe distance, and students will be called via walkie/talkie to go home. Students will not be released to unauthorized individual (i.e: minors under the age of 18, individuals not listed on the student's registration or consent to pick up form, an individual that has been removed from the student's registration per primary caregivers consent) *

I agree

I disagree

An additional release form will be provided. This form MUST be completed and notarized before services start.

Late Pick Up Policy
A late pickup is anytime after the program end time. Specific program times are posted at your school location. All late pick ups will be documented as a written notice. 3 or more notices of late pick ups will result in termination of services

NOTE: We kindly request that parents/guardians cooperate with picking up your students on time. We understand that emergences arise. We also understand that traffic can be challenging or hectic, but expect all children to remain in the program for the required amount of time and be picked up on time. Traffic issues and family emergencies do not excuse the written notice of late pick up.
Late Pickup/No Show Procedures

In the event children are being picked up late, a designated staff member will remain with children until pickup by an adult that is authorized for student pickup.

This designated staff member will also do the following:
1. Contact parent or guardian at home, on his/her cellular phone or at work.
2. Contact persons that are listed on emergency contact information.
3. Contact supervisor to inform him/her that children are being supervised at the site after program hours.
4. Contact local authorities. *

I agree

I disagree

An additional release form will be provided. This form MUST be completed and notarized before services start.

I hereby authorize Big Ideas Educational Services, Inc. to receive information related to my child’s academic information, i.e. I.E.P. – If applicable, FSA & FCAT scores and school grades as authorized by myself or my child’s principal and to use the same in determining an appropriate educational plan for my child. My child’s academic information may NOT be shared outside of Big Ideas for any reason unless such information is made anonymous. *

I agree

I disagree

This statement notifies parents that all student information given to Big Ideas Educational Services, Inc. will be secured (maintain in a locked/secure environment) at the end of each working day. It is also our responsibility to ensure that all computer records maintaining student information is held securely and appropriately protected. In addition, all information obtained will be kept confidential. *

Confirmed receipt of information

• Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

• Section 402.3125(5) F.S., requires that parents requires that parents receive a copy of the Child Care Facility Brochure, ”Know Your Child Care Facility” (CF/PI175-24) or

• Section 65C-20.11(20)(c) (1), F.A.C., requires that a parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28).

• Section 65C-22.006(3)(c), F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility, or

•Section 65C-20.010(6)(c), F.A.C., requires that a written a copy of the family day care provider’s discipline policy be available for review by the patter(s). *

Confirmed receipt of information

I understand that family participation in ALL adult engagement activities are Mandatory. Family non-participation will result in dismissal of services. *

I agree

I disagree

VIRTUAL LEARNING CONSENTS AND DISCLOSURES

To support your child's successful participation in this distance learning program, in what areas might the family and participaiant need extra assistance? *

No Specific help needed

Access to digital device

Access to WIFI Services

Other

Materials Kit Agreement
Students will receive a material kit to participate in the Big Ideas Distance Summer. Students and families agree to following material agreement
1. Bring all material to summer device to participate daily.
2. Manage and up-keep of all provided material. * *

I agree

I disagree

Parent/ Family Responsibilities
1. Assure that a mobile device and internet access are available at home; contact 954-470-0030 if there is a need for a mobile device and/or internet access for at-home use.
2.Monitor Big Ideas daily/weekly email and text communications for up-to-date information regarding distance learning resources and updates.
3. Ensure that your children know their usernames and passwords for instructional resources and encourage their participation in distance learning offerings.
4.Maintain communication with Big Ideas' Staff 954-470-0030
5. Monitor time spent engaging in online and offline learning. * *

I agree

I disagree

Student's Responsibilities
1. Bring all material to summer device to participate daily.
2. Manage and up-keep of all provided material.
3. Dedicate time for scheduled distance learning classes and offline head-sprouts platform.
4.Identify a comfortable and quiet space to learn and study
5. Ensure that you know your usernames and passwords for Head-sprouts instructional resources that are accessible via headsporuts.com website.
6. Engage fairly, respectfully, and safely in all online learning activities being offered by your teachers daily (i.e. Kahoot, head-sprouts, zoom, and all additional platforms added for student engagement). * *

I agree

I disagree

TERMINATION
A family may be terminated from the program for the following reasons:
1. Failure to fulfill the participation commitment as outlined above.
2. Excessive student absents
3. Participant refuse to adhere to the distance learning rules and regulations.
4.Not attending Academic components of distance learning only electives.
5. If Big Ideas Educational Services deems it necessary to remove a family from the program, as defined in its policies and procedures, outlined in the parent handbook. * *

I agree

I disagree

Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.

Signature *

Clear