After School Registration POP Afterschool Enrollment Form Step 1 of 6 16% APPLICATION INFORMATIONApplicant Type(Required)First-Time ParticipantReturning ParticipantTransferring from another POP programEntry Term/Program (When would you like to start?)(Required)Fall/WinterSpringAre you enrolling multiple children?(Required) Yes (If yes, please complete info for all children below under “Demographic”. If you are enrolling more than 4 children please call 215.948.9417 or email [email protected]) No DEMOGRAPHIC INFORMATIONChild #1 Name(Required) First Last Gender(Required) Race/Ethnicity(Required) Current Age(Required) Date of Birth(Required) MM slash DD slash YYYY School Grade Entering in the Fall(Required) Name of School(Required) Child #2 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School Child # 3 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School Child #4 Name First Last Gender Race/Ethnicity Current Age Date of Birth MM slash DD slash YYYY School Grade Entering in the Fall Name of School PARENT/GUARDIAN DEMOGRAPHIC INFORMATIONName(Required) First Last Relationship to "Child(ren)"(Required) Email(Required) Cell Phone(Required)Other PhoneAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently receiving any supplemental assistance programs such as SNAP, TANF, Medicaid, CHIP, LIHEAP or similar benefits?(Required)SNAPTANFCHIPMedicaidOtherNone/Not ApplicableThis is for information purposes only, used for state reporting requirements of individuals we served.HOUSEHOLD INCOME (Please check the appropriate range for your gross family income)(Required)$0 – 10,000$10,001 – 20,000$20,001 – 30,000$30,001 – 40,000$40,001 – 50,000$50,001 – 60,000$60,001 – 70,000$70,001 – 80,000$80,000 – 90,000$90,000+This is for information purposes only, used for state reporting requirements of individuals we served.EMERGENCY CONTACT INFORMATION (other than parent/guardian, if applicable)Emergency Contact # 1 Name(Required) First Last Relationship to Camper(Required) Phone(Required)Is the above-named person allowed to: (Check all that apply)(Required) Caregiver Emergency Contact Authorized for Pick Up Emergency Contact # 2 Name First Last Relationship to Camper PhoneIs the above-named person allowed to: (Check all that apply) Caregiver Emergency Contact Authorized for Pick Up HEALTH INFORMATIONAre there any medical, behavioral, mental health, dietary restrictions, and/or special needs that's important to know about your child(ren) [(asthma, seizures, allergies, diabetes, nosebleeds, ADHD, grief/trauma, oppositional defiance/conduct disorder, autism spectrum, etc.)](Required)Is your child(ren) currently receiving services with this organization or through another agency? If yes, explain what other services they are currently receiving?(Required)Does your child(ren) have an IEP (Individualized Educational Plan)?(Required)Does your child(ren) have any DHS involvement currently or in the past?(Required)Is there a custody agreement in place between primary caregivers?(Required)Do you have anyone in the community who works with your child(ren) to provide them and the family with extra support, for example: Caseworkers/Social Worker, Mentor, Therapist, Psychiatrist, Probation Officer, or other providers? If yes, please explain.(Required)PLEASE UPLOAD A COPY OF PARTICIPANT(S) MOST RECENT PHYSICAL/MEDICAL RECORDS (If enrolling multiple children, attach additional documents below)(Required)Max. file size: 512 MB.FileMax. file size: 512 MB.FileMax. file size: 512 MB.FileMax. file size: 512 MB. CODE OF CONDUCTThe code of conduct for Power of Paint Art Academy & Management (POP Art Academy) programs defines expectations for all participants to ensure that all are safe and to reduce disciplinary problems. A disciplinary problem is defined as one in which a child is hampering the smooth flow of the program by either requiring constant one on one attention; is inflicting physical or emotional harm on other children; is physically or verbally abusing staff or is otherwise unable to conform to the rules and guidelines of the program.Behavioral Expectations and Accountability Guidelines (Please review with participants these program guidelines)(Required) 1. Parents/Guardians: Check in to the assigned program upon arrival to site; check out upon departure. Participants: 2. Do not bring valuables to the facilities. We are not responsible for loss or stolen items. 3. Vandalism of any sort is prohibited. 4. Participants must be respectful toward staff members and fellow students. We have a no-bullying culture at Power of Paint. Bystander behavior must also show respect for all. Respect the rights and privacy of others. If someone wants you to know something about them, they will tell you. Gossiping and talking behind people’s backs is unacceptable. Treat others kindly and expect the same from them. If you have a problem, let a staff person know. 5. Respect the personal dignity, opinions, and possessions of others. Understand that everyone is different. Your ideas might be different, but that does not make you right. If someone chooses not to share possessions with you, that is their decision. Do not play jokes on others. Take care not to hurt, upset, or embarrass anyone. Name-calling is not tolerated. 6. Participant’s must be respectful of others’ property, including, but not limited to property of other students, campers, other participants, and all POP Art’s business supplies, equipment, facilities and property. 7. Treat the employees—of places we visit, eat, or stay—with respect and use good manners. Do everything you can to make their job easier. 8. Stealing is prohibited. 9. Fighting or hitting of any sort is not tolerated. 10. Abusive or offensive language/behavior is not permitted. Participants must always use appropriate language. 11. Participants may not possess lighters/matches, knives, or other dangerous items. 12. Participants must help in cleaning up after themselves in all activities. 1. Code of Conduct 13. Never leave the P.O.P site or assigned group without permission from a P.O.P staff member. 14. Sneakers is recommended at all times; please note that clothing may get messy and may acquire stains based on activities. 15. Please do not bring outside food and/or beverages that may contain common allergens. We are a nut-free and shellfish free campus. 16. Be willing to share information related to the health, safety, and wellbeing of the group. Talking about something that you think we should know is not squealing/”snitching”; it’s making the learning environment safer and better for all. 17. Be aware of the daily schedule and be on time. 18. During transportation, stay seated with your seatbelt fastened, use your inside voice, and treat the bus driver respectfully. 19. Be aware of and abide by all program rules and if you are not sure of something, ask!Corrective Actions and Interventions(Required) 1. Time-Out Process: Participants are expected to follow the program’s behavioral expectations. If a code of conduct violation occurs, a time-out period of 4–15 minutes may be given, with a maximum of 3 time-outs allowed per day. If a participant exceeds 3 time-outs in a single day, a parent/guardian will be contacted to arrange for the participant’s pickup. 2. Continued Behavioral Concerns: If a participant continues to violate the program’s code of conduct after receiving time-outs, the program will contact the participant’s parent/guardian to discuss the behavior. At this point, the participant may be placed on a probationary period to help address the behavior. 3. Probationary Period: If the behavior persists during the probationary period, the participant may be dismissed from the program. Our goal is to help participants develop positive behaviors, but continued violations may lead to this necessary action. 4. Serious Violations: In cases of serious behavior issues such as fighting, vandalism, threatening behavior, or any action that jeopardizes the safety of others, the participant may be immediately expelled from the program. The parent/guardian will be contacted to pick up the participant as soon as possible. ***Note: Exceptions to these guidelines may be made based on the severity of the situation, with the goal of ensuring safety and respect for all participants.Consent(Required) By checking this box, you are consenting that you, as the parent/legal guardian of the above-named child, have understand and have reviewed the code of conduct with your child(ren). This check box represents your signature and indicates your/your child(ren)’s willingness to comply with these expectations and guidelines. Power of Paint reserves the right to dismiss, without refund, any participant whose influence is not conducive for the organization or for other participants. As partners in parenting, we thank you for your willingness to contribute to our positive community. We look forward to a successful, fun, and safe year. WAIVERS & LIABILITYAuthorization for Emergency Medical Care(Required) I hereby give my permission to Power of Paint Art Academy & Management (POP Art Academy) staff to call a doctor or emergency medical service and for the doctor, hospital, or medical service to provide emergency medical or surgical care for my child(ren) should an emergency arise. It is understood that the POP Art Academy’s staff will make a conscientious effort to locate the parent/guardian, or the emergency contact listed on the registration document before any action will be taken. If it is not possible to locate the emergency contact listed, I will accept the expense of emergency medical or surgical treatmentAuthorization to Administer Over-the-Counter Medication Power of Paint Art Academy & Management (POP Art Academy) staff cannot supply your child(ren) with any over the counter medication unless we have a permission on file. If your child(ren) has needs beyond over-the-counter medication, please contact the Executive Director, Teisha Brown, [email protected], to make those arrangements. Please check if you would like your child(ren) to be able to receive over the counter medication at the discretion of staff, for headaches, allergic reactions, etc. I hereby give my permission to POP Art Academy to administer the following to my child(ren), if needed, in the manner described on the packaging: Bug spray, Antibiotic cream, Children’s Tylenol/Motrin, Sunburn cream/ointment, Sunscreen, Heat/cold pack, and/or First-Aid Antiseptic Ointment. If you would like to add a special note for any of the above, please use the additional space in the “Additional Information” section below.Additional Information for "Authorization to Administer Over-the-Counter Medication"Lost or Stolen Items(Required) I understand that Power of Paint Art Academy & Management (POP Art Academy) is not responsible for personal property lost or stolen program participants are using the facilities or on the premisesGeneral Liability Waiver(Required) I, as parent or legal guardians of the above named child(ren), approve and give my permission for him/her/them to participate in any class or program offered by Power of Paint Art Academy & Management (POP Art Academy). By registering for programs through POP Art Academy, registrant acknowledges that the activities carried on in the program can carry certain risks for the participant. Registrant has independently reviewed and evaluated the risks and determined to engage in the program with full knowledge and acceptance of the risk. The registrants agrees to and hereby releases and forever discharge the Power of Paint Art Academy & Management, their officers, employees, agents, facilities, and volunteers from any and all liability for damages, loss or personal injury arising out of or related to registrant’s participation in youth recreational programsBike/Walk To &/Or from Program Permission Form (if applicable) My child has my permission to bike or walk to and from the facilities and be released on his/her/their own. He/she/they will be responsible for signing himself/herself/themself into and/or out of the program each day. I agree that POP Art Academy and employees will not be responsible for the welfare of my child before arrival on the premises and once released to go home each day.Walking/Biking Field Trip Permission Form(Required) We will be leaving the premises on occasions (program & weather-specific) to bike, play tennis, football, soccer, fishing, gardening, etc. Check to give your child(ren) permission to do those activities. My child(ren) has my permission leave the grounds, under staff supervision, for walking/short biking field trips (weather and ability permitting.)Enrollment and Cancellation Policies(Required) 1. Eligibility: The program is open to all students within 5-14 age range who meet the program’s criteria. Priority will be given to students based on local needs, first-come-first-served basis. 2. Enrollment Process: Parents/guardians must complete an initial inquiry/registration form, available online with necessary contact information and emergency details. A confirmation email or phone call will be sent to finalize the registration process which includes all completed waivers. Following successful enrollment, staff will reach out to arrange solidify the logistics, such as pick up time, location, start date, etc. 3. Program Hours: The afterschool program runs from 3pm to 8pm, Monday through Thursday. Please ensure that your child is picked up promptly at the end of the session, if that is arranged. 4. Voluntary Cancellation: If you wish to withdraw your child from the program at any time, please provide at least [number of days] notice to the program coordinator so we can offer the spot to another participant. To cancel, simply [call/email] the program coordinator with your child’s name and reason for cancellation.Emergency Evacuation(Required) I, the parent/legal guardian of the above name minor(s), hereby give permission for my child(ren) to be transported in the event of inclement weather, such as tornado, floods, hurricane, etc., or for the purpose of an emergency evacuation.Promotional/Media Release(Required) I hereby grant Power of Paint Art Academy & Management (POP Art Academy), and their agents consent, and authorize them to use photographic portraits, pictures, digital images or videotapes of my child(ren), or in which my child(ren) may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever related to any and all business related to Power of Paint Art Academy & Management, including but not limited to use in any Power of Paint publication or on the POP Art Academy’s websites, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein my child(ren)’s likeness appears, or the use to which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless POP Art Academy and their agents from all claims, demands, and causes of action that I or my child(ren) have or may have by reason of this authorization or use of my child(ren)’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I understand that in instances where confidentiality is required, this agreement does not apply. I represent that I am at least eighteen (18) years of age and am fully competent to sign this release.Registration Agreement(Required) I agree to the policies and procedures set forth in the Power of Paint Art Academy & Management (POP Art Academy) policies and acknowledge that my child is self-sufficient with regard to toileting, eating and dressing. My child and I have discussed and understand that while participating in POP Art Academy’s programs, the staff is in charge. My child is aware that guidelines and/or instructions made by a staff member are to be followed. I acknowledge that my child has been informed that they have the right to grieve any guidelines they believe may have violated their rights. I accept the Power of Paint Art Academy & Management (POP Art Academy)’s behavior policy.I certify that all information submitted in the enrollment process — including this application and any other supporting materials — is my own (or have legal right to share), factually true, and honestly presented, and that these documents will become the property of the organization to which I am applying and will not be returned to me (copies can be requested in writing for any records.) In place of your signature, please type your full legal name:(Required) ADDITIONAL INFORMATIONShirt Size (select one)(Required)Child’s SmallChild’s MediumChild’s LargeAdult SmallAdult MediumAdult LargeAdult X-LargeOther How did you hear about our program?(Required)Have you previously engaged in any other program at Power of Paint (POP Art)?(Required)YesNoCONTACT DETAILSWhat are the best ways to communicate with you? (select all that apply.)(Required) Email Text Phone Call Standard Mail Consent(Required) I agree to receive text messages from Power of Paint Art Academy & Management (POP Art Academy)Please provide a mobile phone number to receive important updates via text regarding the status of your application and portfolio, important deadlines, and events from Power of Paint (POP Art Academy.)CommentsThis field is for validation purposes and should be left unchanged.