Scholars After School
September 7th, 2021-May 13th, 2022 Student Registration Form
Please print. This form may be used to register up to three children from
the same household.All pages of this form must be completed and signed before a student is eligible for enrollment.
School __________________________

Student Information

1
	
Student’s First Name:
	
Student’s Middle Name:
	
Student’s Last Name:
	
	Student’s Birth Date:
	Gender
M	F	NB/O
	Grade:
	School District ID#:

2
	First Name:
	Middle Name:
	Last Name:
	
	Birth Date:
	Gender
M	F	NB/O
	Grade:
	School District ID#:

3
	First Name:
	Middle Name:
	Last Name:
	
	Birth Date:
	Gender
M	F	NB/O
	Grade:
	School District ID#:

Home Address:
	City:
	State:
	Zip Code:
	Primary Phone:

Student(s) Race: (circle all that apply)
	Languages spoken in the home: (Circle all that apply)
	Student(s) Live With: (Circle all that apply)

American Indian or Alaska Native
	
Asian
	
English
	
Mother
	
Grandmother

Black or African American
	
White
	
Spanish
	
Father
	
Grandfather

Hative Hawaiian or Pacific Islander
	
Other
	
Other:
	
Stepmother
	
Other Relative
	
Student(s) Ethnicity: (Circle Yes or No)
		
Stepfather
	
Other:

Is this child Hispanic/Latinx?
	
Yes
	
No

	
Parent/Guardian Information

1
	
Name of Parent/Guardian (first & last name):
	
Relationship to student(s):

	Primary Phone:
	Secondary Phone:
	Email Address:
	
	Employer:
	Work Phone:

2
	Name of Parent/Guardian (first & last name):
	Relationship to student(s):
	
	Primary Phone:
	Secondary Phone:
	Email Address:
	
	Employer:
	Work Phone:

*Signature: __________________________________ Date: ____________

Please provide contact information on up to two additional emergency contacts Scholars Unlimited can contact in the event the parent/guardian(s) cannot be reached.

1
	
Name of Emergency Contact (first & last name):
	
Relationship to student(s):
	
	Primary Phone:
	Other Phone:

2
	Name of Emergency Contact (first & last name):
	Relationship to student(s):
	
	Primary Phone:
	Other Phone:

Student Medical Information & Emergency Medical Authorization:

Date of most recent Doctor visit/medical check-up:
	
Doctor’s Name/Office:
	Doctor’s Phone:
	
Dentist’s Name/Office:
	Dentist’s Phone:

Please select your preferred hospital in case of an emergency:
(If no Doctor or Hospital is chosen, Scholars Unlimited will use emergency services at Denver Health Medical Center
(303)436-6000, or the Children’s Urgent Care Walk-In Clinic 777 Bannock St. 1st floor, (303)436-6180. If no medical provider is listed Denver Health and the Children’s Urgent Care Walk-In Clinic will be the medical provider of record.)
	
●
	
Denver Health Medical Center, 777 Bannock St Denver, CO 80204; Phone: 303-436-6000
	
●
	
The Children’s Hospital, 13123 East 16th Ave, Aurora, CO 80045; Phone: 720-777-1234
	
●
	
Porter Adventist Hospital, 2525 Downing St, Denver, CO 80205; Phone: 303-778-1955

●
	
Presbyterian St. Luke’s Medical Center (PSL), 1719 E 19th Ave, Denver, CO 80218; Phone: 303-839-6000
	
●
	
Rose Medical Center, 4567 E 9th Ave, Denver, CO 80220; Phone: 303-320-2121
	
●
	
St. Joseph’s Hospital, 1835 Franklin St, Denver, CO 80218; Phone: 303-866-8600
	
●
	
University of Colorado Hospital, Anschutz Campus, 12605 E 16th Ave, Aurora, CO 80045; Phone: 303-372-0000

Other Preferred Hospital (if not listed above):

Does your child/children require support regarding any of the following medical conditions?

●
	
Allergies
	
Please use the space below to list any allergies, specific medical conditions, or medications taken as well as any steps that can be taken to support your child/children:
	
●
	
Asthma
		
●
	
Special Dietary Needs
		
●
	
Hepatits C

●
	
Other physical, medical, or mental health needs:

A current copy of your child/children’s immunization record is required in order for your student to attend Scholars Unlimited. The immunization record must be attached to this form or provided by your child’s school.

●
	
Immunization record attached
	
●
	
Immunization record provided

Student Medical Release Statement & Signature:

I authorize Scholars Unlimited and its major community partners to contact directly the persons designated on this form as emergency contacts, and I authorize the named physician or his/her associates to render such treatment as may be deemed necessary in an emergency for the health of this child. It is understood that a conscientious effort will be made to locate the parent(s) or guardian(s) before any action will be taken. In the event of an emergency, or the parent(s)/guardian(s), or other designated emergency contacts cannot be reached, or if the name of a doctor, dentist, or hospital has not been provided, the staff is hereby authorized to call 911 for immediate medical assistance. The staff is hereby authorized to take whatever action is deemed necessary in their judgment for the health of the child. Parent or guardian agrees to accept all expenses incurred.

*Signature:
	
Date:

Drop off & Pick up Procedure Release & Permission

I understand that Scholars Unlimited and its major community partners are responsible for my student(s) from the time he/she signs themselves into the Scholars Unlimited program until he/she is signed out either by him/herself or by a parent/guardian or other authorized adult. As a parent/guardian of the student(s), I am responsible for my student(s) while he/she is in route to and from the program site, as well as before he/she is signed in and after he/she is signed out.

Drop off/Sign in Permission (please check the box)

●
	
I authorize my student(s) to sign themselves into the Scholars After School program each day.

Pick up or Walk Home Permission (please check only one box)

●
	
I authorize my student(s) to walk home from the Scholars After School program by themselves.

●
	
My student(s) shall always be picked up by an authorized adult (person 18 yrs. or older)

Late Pick up Procedure: It is very important to pick up your student(s) on time. You will be charged a late pick up fee of $5.00 for the first 10 minutes after dismissal and $1.00 for every minute thereafter. Students may not return to the recreation portion of the program until the late pick up fee is paid. If a student is not picked up on time, staff will call all contact numbers on the Emergency Contact List as provided by the parent. Calls will be made 5 minutes after dismissal, and again 10 minutes after dismissal, with final calls being made 20 minutes after dismissal. 25 minutes after dismissal, Scholars Unlimited will notify the police to pick up your student and take him or her to the nearest district Police station. The police will be given the emergency contact information, and they will continue to try to reach someone to pick up the student. This may include the Department of Human Services.

Scholars Unlimited will make every effort to contact someone at the emergency numbers you have provided. In the event of an emergency and you are not able to pick up your student(s) at dismissal time, please notify Scholars Unlimited as soon as possible.

Please remember to notify Scholars Unlimited of any and all emergency phone number changes.

Persons Who MAY NOT Pick Up My Child/Children

Please list any person or persons who are NOT PERMITTED to pick-up your child/children. This includes anyone against whom you may have a restraining order or legal injunction against.

●
	
Do you have a restraining order or court order against the person or persons mentioned above?

Before your child/children attend the program, please provide documentation including a photo for any individuals who may not pick up your child/children.

*Signature: __________________________________ Date: ____________

General Information:
	Please circle Yes or No. Leave none blank.

During this school year, will your children be eligible for the free/reduced lunch program?
	
Yes
	
No

Is your child/children currently on an IEP or in a special education program? (List names of children on IEP below):
	
Yes
	
No

Are there any activities your student cannot participate in due to physical, social or religious reasons?
If yes, please specify:
	
Yes
	
No

Please share with us your child's Strengths. This could include their favorite subjects in school, favorite games and activities or anything else that brings them joy as well as any academic or social-emotional strategies that will support your child/children’s success this school year:

Required Releases
(Scholars Unlimited is a Licensed Child Care Provider. Agreement to the releases below is necessary to provide the safest and most nurturing environment for all children in our program. Please read the releases below carefully and initial next to each.)

Assessment & Records Release: I allow Scholars Unlimited to assess my child's/children's reading and cognitive skills to measure progress, and to access any of his/her/their public school records for diagnostic and program evaluation purposes to be used by Scholars Unlimited program evaluators and for grant reporting.
	
Initial:

Data Collection Release: I understand that Scholars Unlimited holds information and data related to my Child including my Child’s performance and attendance. I understand the success of my Child and the Denver Afterschool Alliance is based on assessment of such information and data. I hereby give permission to Scholars Unlimited to release my Child’s attendance records, grades, and state assessment test (or other test) scores to school districts, City and County of Denver, and providers with District and City approval for the purposes of evaluating the success of the programs and to be able to more effectively serve my Child. I hereby give permission for my Child to respond to anonymous satisfaction and feedback surveys that assess my Child’s experience with Scholars Unlimited and provide feedback on programs, including any impact programs may have had on my Child’s academic performance and/or behavior. I understand that all information collected on my Child will be kept confidential, and that these confidential records will not be used for any purpose other than to evaluate the success of the programs. Data will be released to authorized outside entities for evaluation purposes only and all confidentiality standards will be upheld.
	
Initial:

Personal Release Statement: I understand that there are risks of injury in any recreation or sports activity and that I voluntarily assume such risks. I take full responsibility for the actions and physical condition of my child/children. I agree to indemnify and hold harmless Scholars Unlimited and its major community partners from liability, loss, costs or expenses (including but not limited to: attorney fees, medical, dental or ambulance costs) that my child/children may incur while participating in the Scholars Unlimited program.
	
Initial:

Information Update Agreement: I understand it is my responsibility to keep the information on this form current. I will inform Scholars Unlimited immediately when my phone number, address, employment, child's/children's health/medical information or emergency contact information changes.
	
Initial:

Attendance & Behavior Agreement: I will notify Scholars Unlimited when my child/children will be absent. If my child/children misbehaves or staff has other concerns, I understand Scholars Unlimited staff will communicate and work with me to create a plan that will allow my child/children to participate in a more positive way in the program. A child who is potentially dangerous to other students or staff, or who continually disrupts the program or goals created for the group as a whole will not be allowed to remain in the program.
	
Initial:

Program Permission Release: On my child's acceptance into the program I will receive, read, and sign the Scholars Unlimited Parent Handbook. I am also aware that the complete Employee Handbook is available upon request. I agree to abide by the policies outlined in the Parent Handbook. I further acknowledge that program policies are subject to change at the discretion of Scholars Unlimited.
	
Initial:

SPECIFIC COVID-19 CONSENT: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely dangerous and is believed to be spread from person-to-person contact. The State of Colorado and local governments have determined that businesses may re-open operations at this time. This is not to be seen as any medical or health care determination that COVID-19 is no longer a threat to the lives and health of the citizens of Colorado. Scholars Unlimited has put in place preventative measures to reduce the spread of COVID-19; however, Scholars Unlimited cannot guarantee that you or your child/children will not become infected with COVID-19. Further, your and your child/children's physical presence at Scholars Unlimited activities could increase your risk and your child/children's risk of contracting COVID-19. By agreeing to this statement, I acknowledge the contagious nature of
COVID-19 and voluntarily assume the risk that my child/children and I may be exposed to or infected by COVID-19 by attending activities and that such exposure or infection may result in personal injury, illness, permanent disability or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the activities may result from the actions, omissions, or negligence of myself and others, including but not limited to, Scholars Unlimited employees, volunteers, and their family members. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child/children and myself (including, but not limited to, personal injury, disability or death), illness, damage, monetary loss, claim, liability, or expense of any kind, that I or my child/children may experience or incur in connection with my child/children’s participation at Scholars Unlimited activities (“Claims”). On my behalf, and on behalf of my child/children, I hereby release, covenant not to sue, discharge and hold harmless Scholars Unlimited its employee, agents and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Scholars Unlimited its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after attendance at Scholars Unlimited activities. I agree to protect, defend, indemnify and hold harmless Scholars Unlimited (as well as its volunteers, contractors, officers, directors, employees, representatives, attorneys, and insurers) regarding any of the Claims, and shall be liable to pay attorneys’ fees and costs incurred by Scholars Unlimited or any of the foregoing persons mentioned in this paragraph in the event that I or any person on my behalf bring a Claim that has been otherwise waived by this agreement.
	
Initial:

Optional Releases
(The releases below are optional and Scholars Unlimited is dedicated to ensuring your family's preference in these areas are protected. You may circle "Yes" or "No".)
	Please circle Yes or No. Leave none blank.

Media Release: I give permission to Scholars Unlimited to take and use photographs and video of my child/children for educational and promotional purposes. These pictures/videos may be seen in any media outlet including print, internet, and television. Following an approval process, my child/children may appear in media coverage and promotional information released by Scholars Unlimited and its major community partners.
	
Yes
	
No

Movies Release: I give permission for my child/children to view a maximum of three G-rated and/or PG rated movies on video during the enrichment portion of the program.
	
Yes
	
No

Field Trip/Special Event Permission: I give permission for my child/children to participate in all special trips or excursions where he/she/they may be walking, riding on an RTD or district bus, in a private transportation company bus, or in a Parks & Recreation van, away from the school. (Parents will be notified beforehand of dates and destinations of each excursion.)
	
Yes
	
No

Thank you for completing this form! We are so excited to be able to offer this program to fulfill your family's needs after school and we can't wait to see you this fall!

Please affirm the following:

By signing my name below I authorize my signature to be valid and I verify all information above is correct.

*Signature: __________________________________ Date: ____________