Student Information/Información de Estudiante Name of Student* Nombre de Estudiante
First
Last
Gender* Genéro
Address* Dirección
School* Escuela
Grade / Grado* 2020-2021 School Year / Año Escolar
Teacher*
Birthday* Cumpleaños
Date Format: MM slash DD slash YYYY
T-Shirt Size* Parent / Guardian Contact Information Información De Padres o Tutores
Parent / Guardian #1* Padre/Tutor #1
First
Last
Relationship* Relación
Is Parent #1 Address the same as Student Address?* Address* Dirección
Parent #1 Email* Correro Electronico de Padres #1
Parent #1 Phone Number* # de Telefono de Padres #1
(###)###-####
Authorized to Pick Child Up* Autorizada para Recoger Niño/a
Parent/Guardian #2 Padre/Tutor #2
First
Last
Relationship Relación
Is Parent #2 Address the same as Student Address? Address* Dirección
Parent #2 Phone Number # de Telefono de Padres #2
Parent #2 Email Correro Electronico de Padres #2
Authorized to Pick Child Up Autorizada para Recoger Niño/a
Emergency Contacts Contactos Emergencias --
(Other than those listed above)
Emergency Contact #1 Contacto Emergencias #1
First
Last
Relationship Relación
Phone # # de Telephono
Authorized to Pick Child Up Autorizada para Recoger Niño/a
Emergency Contact #2 Contacto Emergencias #2
First
Last
Relationship Relación
Phone # # de Telephono
Authorized to Pick Child Up Autorizada para Recoger Niño/a
Pick Up Information / Información para Recoger Please list any other people who are authorized to pick up your child.
Por favor, ponga otra persona/s queen tiene autorización para recover su niño/a
Authorized Pick Up Autorizada para Recoger Niño/a
First
Last
Relationship Relación
Phone # # de Telephono
Authorized Pick Up Autorizada para Recoger Niño/a
First
Last
Relationship Relación
Phone # # de Telephono
Permission to walk home / Permiso para caminar a casa My child has permission to walk home at:
A Tiene permiso para caminar a casa a:
Initial Iniciales
Medical Information Información Medical
Hospital Name Nombre de Hospital
Doctor’s Name Nombre de Doctor
Doctor's Address Dirección de Doctor
Insurance Company Compañía de Seguros
Policy Number Numero de Poliza
Allergies and Medical Conditions Alergias y Condiciones Medicas
Special Needs Necesidades Especiales
Medications Medicamento
COVID-19 Questions / Questiones de COVID-19 Is there an adult that stays at or is working from home to watch your child?* ¿Hay un adulto que se queda o trabaja para cuidar a su hijo?
Is one or more of the child's parents working outside of the house?* ¿Uno o más de los padres del niño están trabajando fuera de casa?
What days is your child attending school in-person? ¿Qué dias asiste su hijo a la escuela en persona?
Is your child attending the FSD Extended Care Program?* ¿Su hijo asiste al programa FSD Extended Care?
RELEASE OF RESPONSIBILITY RELATED TO COVID-19 / LIBERACIÓN DE RESPONSABILIDAD RELACIONADA CON COVID-19* OC United will follow the guidelines published by the (Center for Disease Control) CDC including 6 feet of social distancing wherever possible in the building and implementing additional disinfecting procedures (e.g. cleaning surfaces in the office between clients). Masks should be worn by program participants both inside and outside while activity is in session. Masks may be removed during activity with appropriate social distancing between staff and program participants to facilitate easier communication.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We are safe here/ Estamos seguros aqui
House Rules Agreement/Acuerdo de Reglas de Casa Please read the outline of our United Kids House Rules following this page, and sign below agreeing to aim for these rules. If there are issues surrounding these rules, we reserve the right to suspend or remove any child from our program.
Por favor, lea el contorno de nuestros United Kids House Rules siguiendo este pagina, y firma abajo acordando para trabajar hacia estas reglas. Si hay problemas siguiendo estas reglas, reservamos la derecho para suspender o remover al niño/a de nuestro programa.
Agreement - We are safe here/ Estamos seguros aqui* At United Kids, we know that we do not have to be afraid. We do not have to be afraid of being in danger, but we also do not have to be afraid of each other. Because we are safe here, we do not hurt others-- with words or actions-- but make sure that each of us are safe while at United Kids.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We are safe here/ Estamos seguros aqui
Agreement - We feel our emotions / Sentimos nuestros emociones.* Our emotions matter-- so much that a lot of what we do at United Kids has to do with them. At United Kids, we feel our emotions and show the real version of ourselves. We can trust that the friends we make and the adults we meet are showing the real them, not a fake them.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We feel our emotions. / Sentimos nuestros emociones.
Agreement - We heal what is hurt/ Curamos lo que ha sido lastimado* The world hurts sometimes, but we don’t leave it that way. At United Kids we go back to heal what is hurt. Sometimes this means saying sorry, other times it’s dreaming for something better. When we are at United Kids, we don’t leave things broken.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We heal what is hurt./ Curamos lo que ha sido lastimado.
Agreement - We dream big together / Soñamos en grande juntos* We imagine a future that excites us. What we want the world, our neighborhood, our family, or our lives to be starts with dreaming big. At United Kids, it’s not only safe to dream, we dream together.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We dream big together. / Soñamos en grande juntos.
Agreement - We learn with fun / Aprendemos con diversión* While we are going to learn a lot at United Kids, most of the time you won’t realize it! At United Kids, we have fun, with a purpose. This might mean we stop to think about how we feel or what we think before and after a game. This is because being part of United Kids means we use fun to grow into better people.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We learn with fun. / Aprendemos con diversión.
Agreement - We are family / Somos familia* Nobody is left out at United Kids. United Kids is a family that cares about each other. Family is honest, family cares for each other, family grows together. Whether it's when we are eating together, playing together, or getting to know each other, every person is welcome as a part of our United Kids family.
We have read and agree/Nosotros hemos leído y estamos de acuerdo --- We are family. / Somos familia.
Authorization & Release AUTHORIZATION FOR MEDICAL TREATMENT & RELEASE OF RESPONSIBILITY / AUTORIZACIÓN PARA TRATAMIENTO MÉDICO Y LIBERACIÓN DE RESPONSABILIDAD* I, the undersigned parent or guardian of the aforementioned child, do hereby grant consent for staff and volunteers of OC United and affiliated programs to seek and agree to such medical treatment as in their opinion is necessary for the health, safety and welfare of the above-named minor. I also grant consent to any x-ray, examination, anesthetic, medical or surgical supervision and on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful. This consent is being granted specifically for OC United programs involving the youth. I agree to release and hold harmless all staff and volunteers of OC United from any and all claims, suits, costs and actions, of any kind whatsoever, arising from their exercise of the power granted by this authorization. Also, I hereby release and hold harmless the program it’s staff, employees, agents, officer and directors, from any and all claims, suits, cost and actions, of any kind whatsoever, arising from their conduct related to all 2020-2021 School Year activities.
We have read and agree / Nosotros hemos leído y estamos de acuerdo
PERMISSION TO USE PHOTOGRAPHS AND WRITTEN TESTIMONY / PERMISO PARA USAR FOTOGRAFÍAS Y TESTIMONIO ESCRITO* I give permission for the OC United and affiliated programs permission to use my child's pictures in publications and promotional material. Your signature below indicates your permission for such to be used in OC United publications without charge to the organization.
We have read and agree / Nosotros hemos leído y estamos de acuerdo
RELEASE OF AND PERMISSION TO ACCESS INFORMATION / LIBERACIÓN Y PERMISO PARA ACCEDER A LA INFORMACIÓN* I undersigned parent or guardian of the aforementioned child, do hereby grant OC United, and all staff working with my child, permission to access information, legal, school-related or otherwise, concerning my child. The Director, or other staff, are knowingly acting in any advocacy capacity for my child and will use this information only for professional and confidential use.
We have read and agree / Nosotros hemos leído y estamos de acuerdo
Student Signature/Firma de Estudiante* Parent/Guardian Signature / Firma del Padre/Madre o Tutor CAPTCHA
