FALL UNITY 4 TEENS REGISTRATION FORM

FOR OFFICE USE ONLY
Eligibility
(Check All that Apply)
Brian C. Faso, Principal
Assigned Teacher
FALL UNITY 4 TEENS REGISTRATION FORM
Directions:
1. Student completes the STUDENT INFORMATION Section
2. Parent completes the PARENT/LEGAL GUARDIAN Section
3. Sign the front and back of the registration from. If the student is a minor, parent must sign the
front and the back of the registration form. (There are 2 signature lines on the back of the form).
 Free and/or Reduced
Lunch
 FCAT Scores
 Reading Assistance
 Life Skills Support
 Attachment to School
STUDENT INFORMATION
Last Name
First
Student ID#
Grade
Date of Birth
(mm/dd/yyyy)
Last 4 digits of social #
Male
Female
Race:
COUNTRY of Birth
African American/Black
White
Hispanic
Language(s) Spoken at Home
Email
Cell Phone
Street Address
Apartment/Unit #
City
State
# of People in the Household
Total Household Income
Single
Other ________________
Zip
Dual Parent Home
$10K-$19K
$20K-$29K
$50K-69K
$70K- 100K
$30K-$39K
$40K-49K
$100K- Over
Transportation: (check ONE of the following three choices)
I walk home at dismissal
My parent will pick me up at dismissal
I will need transportation home after activities
(outside two-mile limit)
Extra-Curricular Interest:
Area(s):
PARENT/LEGAL GUARDIAN INFORMATION
Mother’s Name
Father’s Name
COUNTRY of Birth
COUNTRY of Birth
Phone 1
Phone 2
Email
Phone 1
Phone 2
Email
I would like assistance with:
Benefits and Work Support
Financial and Wealth-Building Services
Employment and Career Advancement
Basic legal Aid / Foreclosure Prevention
ACKNOWLEDGEMENT SIGNATURE
(IF A STUDENT IS A MINOR, PARENT SIGNATURE IS REQUIRED)
I give consent for my son/daughter to participate in the afterschool program at Miramar High School.
Parent or Student Signature _____________________________________________________ Date ______________________
SEE REVERSE SIDE FOR ADDITIONAL REQUIRED SIGNATURES
REQUIRED CONSENT FOR PARTICIPATION
CLIENT’S RIGHTS
All clients shall enjoy all of their legally entitled rights, and in addition can expect the following rights to be honored while receiving any service at Hispanic Unity of Florida, Inc:
Access to all of the services we provide and/or referral to other appropriate services (based on individual need); To be treated with respect and served in a culturally appropriate
and sensitive environment; To receive requested information/assistance/referral in a timely manner and be served in an environment free from all forms of harassment; To be
given the opportunity to provide feedback to the Executive Director and the Board of Directors regarding the service they are receiving; Upon enrollment, to be able to freely
choose to participate or cease to participate in any of the agency’s services; and To be aware of grievance procedures that may be utilized when needed.
CONFIDENTIALITY AGREEMENT
Hispanic Unity of Florida recognizes that any information obtained is of a confidential nature. Hispanic Unity of Florida and its employees agree to fully comply with preserving
confidentiality and agree not to divulge or discuss confidential information for any purpose or in any matter not in conformity with the State of Florida or Federal law, except for
the purpose of administrating this program.
RELEASE OF INFORMATION
I hereby authorize Hispanic Unity of Florida to obtain/release information about my child from/to the following organizations: School Board of Broward County and
Children’s Services Council of Broward County (funder). I am aware that data collected and analyzed maybe shared with other stakeholders.
MEDICAL AUTHORIZATION
I authorize the Executive Director of Hispanic Unity of Florida or its staff to obtain necessary medical services or emergency medical services to assure my son/daughter’s health.
I understand that if any medical procedure is necessary although act due to an emergency, all reasonable attempts will be made to contact me.
WAIVER OF LIABILITY
I do hereby release Hispanic Unity of Florida, its officers, agents and employees from and against any and all claims or demands of any kind or nature that may accrue in my favor
on account of my child’s/my participation in the program. This includes any activity or event sponsored by Hispanic Unity during the program. The provisions of this release and
hold harmless shall apply whether or not the claim or demand results in whole or in part from any negligent or contributory negligent act or omission on the part of Hispanic Unity,
its officers, agents or employees, or any combination thereof. Nothing in this agreement shall be construed to affect the rights, privileges and immunities of Hispanic Unity under
the doctrine of “Sovereign Immunity” and as set forth in Section 768.28 statues.
GRIEVANCE PROCEDURES
If you feel that your services have been denied incorrectly or have not been provided fairly or reasonably, you may present your concerns, verbally and in writing, within three (3)
business days following such action, to supervisory staff who will review the circumstances and render a decision within three (3) business days of receiving your complaint. If the
matter is not resolved to your satisfaction, you may send a written request to the agency’s grievance committee chairperson, who will investigate and assign a hearing date for
you to present your case before the grievance committee within three (3) business days from the date they receive you request. You will have a final decision within four (4)
business days following your hearing. Forms and a copy of the complete appeals/grievance policy is available from any Hispanic Unity of Florida office. You have a right to seek
legal recourse, through your own independent counsel if you believe that civil rights or confidentiality laws were violated in your case; however, you may request to resolve the
issue through the agency’s appeal/grievance process.
I have read and understand the policies outlined above. I understand that if I do not consent to the policies stated above my
son or daughter cannot participate in the After School Program. (If student is a minor, a parent signature is required)
Parent or Student Signature X __________________________________________ Date _____________________
ADDITIONAL CONSENT
PHOTO RELEASE
____ I PERMIT Hispanic Unity and funders to take photographs and/or digital video images of me/my child and to use and publish such photographs, together with any caption
or descriptive material, including my name, that HUF may choose, for advertising, publicity, or any other purpose in the HUF direct mail pieces, inserts and other related
promotional medium, or in any other publication or manner HUF may authorize. I waive the right to inspect or approved any photographs or digital video images before they are
published and any use to which they may be put. I release HUF its officers, agents and employees of and from all debts, claims and liability of any kind arising out of or in
connection with the taking and use of photographs, the use of my name and the use of any caption or descriptive material therewith.
_____ I DO NOT give permission for HUF and funders to take photographs and/or digital video images of me/my child.
CONSENT OF PARTICIPATION IN THE TEEN OUTREACH PROGRAM AND SURVEYS & DATA COLLECTION
I understand that my son/daughter may participate in the Teen Outreach Program (TOP), replicated at Stranahan High School, provided by Hispanic Unity of Florida and owned by
Wyman Center, Inc (Wyman) as part of the After School program. During the time your child may spend in the TOP group, young people will explore their own growth and
development, their goals for the future, and their goals for close and productive relationships with others. This program has been evaluated nationally and has shown very
positive results for young people. This unique program will involve your child in volunteer work in the community. This work may occur off school grounds. The program
promotes progress in school and avoidance of behaviors which hinder your child’s most successful growth and achievement.
I give my consent for my child to participate in Wyman surveys. In compliance with Children’s Online Privacy Protection Act (COPPA), Wyman provides the following information
to survey participants. Wyman Center, Inc. operates a secure environment to collect and store information from student participants in its Teen Outreach Program. Wyman
collects the following types of information directly from TOP participants through online surveys: Opinions about their experience in TOP; Demographics (zip code, ethnicity,
gender, most frequent guardian, parents’ educational level); School records (grade in school, absences, truancy, suspension, course failure, graduation and schooling plans); and
Health information (pregnancy, parenting). Wyman uses the participant’s responses to improve the Teen Outreach Program. I understand that survey and data collection is
voluntary and that my child may choose to participate or discontinue participation at any point in the process without risk of losing Wyman’s services. I am also aware Wyman will
not require my child to disclose more information than is reasonably necessary to participate in TOP as a condition of participation. I am aware Wyman will use and may share
responses with third parties to market TOP to increase awareness and funding and that Wyman will not disclose my child’s identifying information to third parties or program staff.
I also understand that the associated risks for my child to participate in this survey is minimal and will not exceed any discomfort that may be found in any daily life situations
when answering routine survey questions. For a sample report on how Wyman compiles and reports this data, go to www.wymantop.org. Wyman Representative: Mindy Sharp,
Sr. V.P., Finance and Administration; 600 Kiwanis Dr, Eureka, MO 63025; (636)938-5245
_____Yes
_____No
(If student is a minor, a parent signature is required)
Parent or Student Signature X __________________________________________ Date ___________________