The Digital Explorers program, primarily funded by the United Way of Broward County and the Jim Moran Foundation, offers free in-school, after-school and summer enrichment for middle school students in the form of quality STEM education and career exploration.

Section 1: Program Location

School Name *

Section 2: Student Participation Information

Student Name *Date of Birth *School ID Number *Grade *— Select Choice —56789Gender *— Select Choice —MaleFemaleNon-binaryPrefer not to sayRace/Ethnicity *— Select Choice —BlackWhiteHispanicMulti-RacialAsianPacific IslanderAlaskanNative AmericanOther

Section 3: Parent / Guardian Information

Parent/Guardian Name *Phone *

Email *

Additional Parent/Guardian NamePhone

Email

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Section 4: Family Background (if applicable)

Primary Language(s) Spoken at Home *— Select Choice —EnglishSpanishFrenchCreoleEnglish Proficient *— Select Choice —YesNoStudent's Country of Birth *Military Family *— Select Choice —YesNoAnnual Household Income *— Select Choice —$10,000–$19,999$20,000–$29,999$30,000–$39,999$40,000–$49,999$50,000–$59,999$60,000–$69,999$70,000–$79,999$80,000–$89,999$90,000–$99,999$100,000+Household Arrangement *— Select Choice —Lives with MotherLives with FatherLives with Both ParentsLives with GrandparentsOtherNumber of Persons in the Household *— Select Choice —2345+PreviousNextSave and Resume Later

Section 5: After-School Mode of Transportation

Any change to this section must be done in writing by the parent/guardian completing this form.

Section 6: Student Participant Medical Information

If none, type N/AAllergiesMedicines Currently TakingDietary RestrictionsOther (IEPs, 504 Plans)

Section 7: Emergency Contacts

Name *Phone *

Email *Relationship to Student *

NamePhone

EmailRelationship to Student

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Section 8: Confidentiality of Records

The confidentiality of child records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a child attends the program, or disclose any information identifying a child UNLESS:

1. The child consents in writing;
2. The disclosure is allowed by court order or;
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation or;
4. The child commits or threatens to commit a crime either at the program or against any person who works for the program.

Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs. Federal law and regulations do not protect any information about suspected child abuse from being reported under State law to appropriate State or Local authorities.

(See 42 U.S.C. 29Odd-3, 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations.)

Student Participant Name *Parent/Guardian Name *Student Participant Signature *

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Parent/Guardian Signature *

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Section 9: Field Trip Permission Slip

Student Participant Name *School *Student ID Number *Parent/Guardian Name *Parent/Guardian Signature *

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Section 10: Consent & Release

Parent/Guardian Name *Parent/Guardian Signature *

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Section 11: Service Contract

Student Name *DateSchool *Student ID Number *

I hereby grant permission to the School Board of Broward County (SBBC) to disclose treatment records and progress to the CROCKETT FOUNDATION.

The purpose of the disclosure authorized herein is for service delivery and treatment planning.

The Crockett Foundation may obtain and have access to, for the purpose of academic progress monitoring, the following school records related to my child’s education:

• Attendance Reports
• Report Cards
• Interim Reports
• Individualized Educational Plans (IEP)
• 504 Plans

I am aware that, as the provider of funding for this program, the Crockett Foundation reserves the right to conduct a survey of persons whose services are paid for by this contract for the purpose of Aftercare / Follow Up evaluation. This survey may require the use of a uniform instrument and may be administered up to 18 months after discharge.

In addition, I authorize the release of information, contained in school records, regarding my child’s academic progress to the program’s FUNDING PARTNERS. A list of the funding partners can be found at the Crockett Foundation website.

I understand that I may revoke this consent at any time except to the consent that action has been taken into reliance on it, and that, in any event, this consent expires automatically three (3) years after the date listed above.

Parent/Guardian Name *Parent/Guardian Signature *

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Section 12: Statement of Child Rights

The rights as a child are protected by law and you have the right to be informed about such rights. Your child has THE RIGHT TO:

INDIVIDUAL DIGNITY

• Be respected at all times and upon all occasions.
• Have freedom of movement, unless restriced as a part of treatment, and to be free from abuse or neglect.

SERVICES

• Receive services, regardless of your ability to pay.
• Receive an appropriate setting based on individual needs.
• Be provided the opportunity to participate in activities designed to enhance self-image.
• To participate in the development of individual goals.

QUALITY CARE

• Receive services delivered by skilled and professional staff members.
• Receive such social, educational, and recreational services as needed.
• Have access to a telephone at any time to report abuse or neglect – (800) 962-2873.
• Receive a copy of the program description to include rules concerning written and verbal communications, program activities, privileges/restrictions and rules/consequences.

GRIEVANCES PROCEDURE

It is the policy of this agency to ensure that the child’s rights are protected by providing a formal grievance procedure. Grievances related to the youth program may include conflicts between children and/or conflicts between children and Crockett Foundation staff. If a problem emerges, take the following steps to arrive closer to a resolution:

1. Speak directly with the Site Supervisor and provide him/her with details on the matter.
2. If unresolved, contact the Program Manager and provide him/her with details on the matter. A reply to your concern(s) shall be made within 24 hours.
3. If still unresolved; contact the Program Director and provide him/her with details on the matter. A reply to your concern(s) shall be made within 48 hours.

Parent/Guardian Name *Parent/Guardian Signature *

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Section 13-A: Discipline Matrix

The Discipline Matrix sets forth the guidelines for assessing consequences for violations of the select youth program conduct policies. The Program Manager(s) have the discretion to recommend to the Director a deviation from these guidelines by assessing an appropriate consequence other than one stated in the Matrix, if s/he determines in his or her sole discretion, that there are mitigating or aggravating circumstances. Furthermore, the Crockett Foundation reserves the right to deviate from the established disciplinary action if it is determined that the behavior(s) were found to be inciteful and/ or egregious.

Section 13-B: Student Discipline Policy

All Crockett Foundation staff use positive reinforcement and rewards, but at times they may encounter undesirable behavior(s) by participant(s). Persistent behaviors and/or incidents are defined as behaviors that create safety concerns for program participants and/or staff. When a child exhibits and displays one or more of the following behaviors they will receive a consequence that suits the unsafe behavior, which could range from a disengagement from aversive activity, parent conference, suspension, loss of a field trip, or expulsion from the program. In extreme situations, where the child’s behavior is dangerous to staff or participants, the Crockett Foundation reserves the right to forego our standard discipline policy and move forward with immediate expulsion of the child from the youth program.

The Crockett Foundation encourages parents to keep an open line of communication with our staff.

We care about every child and we strive to create a safe and enjoyable experience for each student participant. 

Student Participant Name *Parent/Guardian Name *Student Participant Signature *

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Parent/Guardian Signature *

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Section 14: Extra-Curricular Activities Consent & Release

The purpose of the disclosure authorized herein is for treatment planning and service delivery. I understand that I may revoke this consent at any time except to the consent that action has been taken in reliance on it, and that, in any event, this consent expires automatically three (3) years after the date of the signature below.

The Crockett Foundation (CF) is dedicated to supporting youth development through activities that enhance health, wellness, and academic growth. Some of our participants may have extracurricular activities scheduled after school, which may overlap with CF programming.

If your child wishes to attend these activities, we require written permission for them to leave our program. Please note that the Crockett Foundation cannot assume responsibility or liability for any incidents that occur during this time when your child is outside of our direct supervision.

After their extracurricular activities have concluded, student participants are welcome to return to CF programming until dismissal. Once they return, they must sign in under CF supervision. Parents and guardians can then pick up their children at our designated single point of entry. 

Student Participant Name *School *Student ID Number *Parent/Guardian Name *Parent/Guardian Signature *

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Section 15: Media Release Form

The purpose of the disclosure authorized herein is for treatment planning and service delivery. I understand that I may revoke this consent at any time except to the consent that action has been taken in reliance on it, and that, in any event, this consent expires automatically three (3) years after the date of the signature below.

I understand that the Crockett Foundation, Inc. (CF), the Children’s Services Council of Broward County (CSC), the United Way of Broward County (UWB), and Frederick A. Deluca Foundation (FDF) may desire to use photographs of my child, which may be published in the aforementioned agencies’ promotional materials, literature, website, direct mail pieces, inserts, and other related marketing media. 

Name *School *Student ID Number *Parent/Guardian Name *Parent/Guardian Signature *

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Section 16: SBBC Student Data Authorization

The Digital Explorers program operated by the Crockett Foundation, Inc. is primarily funded by the United Way of Broward County (UWBC). The UWBC uses student data from the School Board of Broward County (SBBC) to research and evaluate the success of the program operated by the Crockett Foundation, Inc. To use SBBC data, the SBBC requires parents/guardians or students 18 years of age or older to read and sign the information below.

“The SBBC shares data with the UWBC, for the purposes of: (1) enrolling students into UWBC programs; (2) researching and evaluating the effectiveness of UWBC programs at improving student’s school performance, behavior, attendance, graduation rates, and their transition to career pathways; and, (3) care coordination purposes. The shared education records include: students’ first and last names; student SBBC identification number; race; gender; disability; home language; country of origin; eligibility for free and reduced lunch; English proficiency; Florida student identification number; home address; attendance; schedule; grades; test scores; promotion status; risk assessment data; career technical education credential attainment; suspensions and/or expulsions.

The education records listed above will be disclosed by SBBC to the UWBC and the Crockett Foundation, Inc. so the Crockett Foundation, Inc. can effectively provide case coordination services to help students improve the following metrics school performance; behavior; attendance; graduation rates; and their transition to postsecondary opportunities.

By signing below, the parent/guardian or student 18 years of age or older provides their expressed written consent for SBBC to disclose their child’s school records pursuant in the paragraphs above.

Parent/Guardian Name *Parent/Guardian Signature *

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Section 17: Attendance Policy

The Crockett Foundation strives to provide quality after school and summer programming at no cost to the children and families we serve on school and non-school days. Every student participant in the Crockett Foundation programs receives a scholarship through our funders to be a part of the after-care and summer program. Criteria for eligibility for the scholarship comes from your child’s attendance. Without consistent attendance and your child’s presence throughout programming hours, we cannot keep this program running at no cost.

To continue qualifying as a recipient of the scholarships provided, all students must attend the full program daily. Our program hours, unless otherwise modified by school officials, are as follows:

• Afterschool sessions: Monday through Thursday, 4 pm through 6 pm
• Summer sessions: Monday through Thursday, 9 am through 4 pm

Due to the nature of our funding structure, our attendance policy can only allow for three (3) absences per month with at least 48-hour notification given to the program staff.

In addition, student(s) CANNOT be signed out early more than three (3) times per month. Only persons listed in the registration application are authorized to sign out the student.

The Crockett Foundation will institute a $15 late pickup fee for any student that is picked up after 6:05 pm for afterschool sessions and 4:05 pm for summer sessions. In addition to the $15 late pickup fee, there will be a $5 fee for each additional 15 minutes. After three (3) late pickups, the student will be ineligible to continue participating in the after-care program(s) for the remainder of the program. Failure to pay the fine may also result in a suspension or dismissal from the program.

Please be advised that space is limited and participants that DO NOT meet our attendance and tardy policies will lose their scholarship and eligibility to participate in youth development programming, field trips, incentive activities, and summer camps. The terms of this policy are effective upon enrollment in the selected program.

Parent/Guardian Name *Parent/Guardian Signature *

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Section 18 – Before & After School Child Care Program

Student Information

Student Name *Student Number *Student DOB *Grade *— Select Choice —56789Eye Color *Hair Color *Gender *— Select Choice —MaleFemaleNon-binaryPrefer not to sayWeight *Race *— Select Choice —BlackWhiteHispanicNative AmericanMultiracialAsianOtherHeight *Home School *Teacher's Name *Child Lives With *— Select Choice —Both ParentsMotherFatherGuardianShared CustodyOtherCan your child be photographed? *— Select Choice —YesNoList all siblings attending the program at this time below

Registering Adult

Name *Home Phone *

Cell Phone *

Cell Phone Provider *Work *Email *Adult Password *

Secondary Adult

NameHome Phone

Cell Phone

Cell Phone ProviderWorkEmailAdult Password

Medical Conditions

Family Doctor *Doctor Phone *

Does your child have any medical conditions? If yes list belowDoes your child have any allergies? If yes list belowDoes your child take any medications? If yes list belowDoes your child have any special concerns we should be aware of?Does your child have any special needs we should be aware of?Does your child receive any special services during the school day?

Adult Authorized Release/Contact

NameRelationshipHome Phone

Work/Cell Phone

NameRelationshipHome Phone

Work/Cell Phone

NameRelationshipHome Phone

Work/Cell Phone

I declare this information to be true and correct. I will notify the Supervisor immediately of any changes.

Name *Relationship to child *Date / Time *Signature *

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