Youth Program Application - Crockett Foundation

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- Step 1 of 16

The youth program services offered through this application are centered on enrichment activities dedicated to academic support, STEM instruction, and positive youth development.

Section 1: Program Information

Program Location *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)
Other

Where?

Which program are you applying for? *

Section 2: Student Participation Information

Student Name *

Date of Birth *

School ID Number

Gender *

Race/Ethnicity *

Grade *

Section 3: Parent / Guardian Information

Parent/Guardian Name *

Phone *

Email *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Parent/Guardian Name

Phone

Home Address (if different than above)

Address Line 1

Address Line 2

City

State

Zip Code

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Section 4: Family Background (if applicable)

Check all that apply. *

West Indian
Dominican
Cuban
Haitian
Puerto Rican
Central/South American Hispanic
English
Irish
German
Russian
Italian

Language(s) spoken at home *

English
Spanish
Creole
French
Portuguese
Other

Other language(s)

English Proficient *

Student's Country of Birth *

Military Family *

Annual Household Income *

Household Arrangement *

Number of Persons in the Household *

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Section 5: After-School Mode of Transportation

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

After-School Mode of Transportation *

Walker
Car Rider
Both

Section 6: Student Participant Medical Information

Allergies *

Enter N/A if this doesn't apply.

Medicines Currently Taking *

Enter N/A if this doesn't apply.

Dietary Restrictions *

Enter N/A if this doesn't apply.

Other (IEPs, 504 Plans) *

Enter N/A if this doesn't apply.

Section 7: Emergency Contacts

Emergency contacts must be someone other than primary Parent/Guardian.

Name *

Phone *

Relationship to Student *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name

Phone

Relationship to Student

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

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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:

The child consents in writing;
The disclosure is allowed by court order or;
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation or;
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.)

Checkboxes *

I have read and understood the above statement regarding the confidentiality of records.

Student Participant Name *

Parent/Guardian Name *

Student Participant Signature *

Clear Signature

Parent/Guardian Signature *

Clear Signature

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Section 9: Field Trip Permission Slip

Permission Slip 1 *

I hereby give permission to my child to attend all field trips, community service learning projects, and career exploration events hosted by the CROCKETT FOUNDATION, INC. I also give the Crockett Foundation the permission to transport my child via private transportation company and/or private service provider.
I DO NOT give permission to my child to attend all field trips, community service learning projects, and career exploration events hosted by the CROCKETT FOUNDATION, INC. I also give the Crockett Foundation the permission to transport my child via private transportation company and/or private service provider.

Permission Slip 2 *

I am aware of the nature of the field trips and I hereby assume all responsibility for my child’s participation therein, and thereby agree to hold harmless and indemnify THE CROCKETT FOUNDATION, INC., its Board of Directors, and/or its employees, agents, or lessors from any and all claims, including any negligent act or contributory negligence, raised by myself, my child, my heirs, my family, or my assigns.

Student Participant Name *

School *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)

Student ID Number

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 10: Consent & Release

Consent 1 *

I give permission for my child to participate in the youth program furnished by the Crockett Foundation, Inc.

Consent 2 *

I also agree to meet with the program staff on a regular basis in order to contribute to my child’s progress. I understand that my participation in the program is required and that my nonparticipation may result in my child’s withdrawal from the program.

Consent 3 *

It is the understanding that my child will participate in the designated Crockett Foundation program for a minimum of two (2) hours per program day to maximize the program’s intended benefits.

Consent 4 *

I agree to allow my child to participate in follow-up services provided by the Crockett Foundation staff upon completion of the program. I understand that all information concerning my child will be kept confidential within legal limits.

Consent 5 *

I also give my permission to the Crockett Foundation program staff to provide my child with transportation for emergency or medical reasons, field trips, and home, when necessary.

Consent 6 *

I am aware that external agencies related to the funding of the Crockett Foundation youth programs may contact me for follow up information.

Consent 7 *

I understand that I may revoke this consent at any time, except to the extent that action has been taken in regard to the case, and that, in any event, this consent expires automatically at the end of the school year.

Consent 8 *

I have read and understood the above statements regarding the consent and release policy related to the Crockett Foundation youth programs.

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 11: Service Contract

Student Name *

Date *

School *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)

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 *

Clear 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.

Checkboxes *

I have read and understood the rights afforded by the agency to the child participating in the youth program.

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:

Speak directly with the Site Supervisor and provide him/her with details on the matter.
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.
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.

Checkboxes *

I have read and understood the agency’s policy and procedures related to grievances.

Parent/Guardian Name *

Parent/Guardian Signature *

Clear 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.

Checkboxes *

I have reviewed the Discipline Matrix and the Student Discipline Policy and hereby promise to adhere to the aforementioned program rules, policies and procedures.

Checkboxes (copy) *

I understand that failure to adhere to the aforementioned program rules, policies and procedures so will result in a disciplinary action, as outlined in the Crockett Foundation Discipline Matrix.

Student Participant Name *

Parent/Guardian Name *

Student Participant Signature *

Clear Signature

Parent/Guardian Signature *

Clear 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.

Multiple Choice *

I AGREE to release my child from CF programming so that they can attend their designated extra-curricular activity. I understand that the Crockett Foundation is not responsible or liable for any incidents that occur while my child is participating in that extra-curricular activity.
I DO NOT AGREE to release my child from CF programming for any extra-curricular activity.

Student Participant Name *

School *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)

Student ID Number

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 15: Media Release Form

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.

Photography Consent - Media Release Form *

I hereby consent and give CF, CSC, UWB, and FDF permission to take photographs, and/or digital video images of my child and to use and publish such photographs, video images together with any caption or descriptive material, including my name, the agencies’ names listed herein, for advertising, publicity, or any other purpose the aforementioned agencies desire and authorize.
I hereby DO NOT consent and give CF, CSC, UWB, and FDF permission to take photographs, and/or digital video images of my child and to use and publish such photographs, video images together with any caption or descriptive material, including my name, the agencies’ names listed herein, for advertising, publicity, or any other purpose the aforementioned agencies desire and authorize.

Checkboxes *

I waive the right to inspect or approve any photographs or digital video images before they are published and any use to which they may be put.

Permissions *

I release the Crockett Foundation, Inc., the Children’s Services Council of Broward County, the United Way of Broward County, and the Frederick A. Deluca Foundation, 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 and video, the use of my name and the use of any caption or descriptive material therewith.
I DO NOT give consent nor give permission to CF, CSC, UWB, and FDF to publish photographs and/or digital video images of my child.

Name *

School *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)

Student ID Number

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 16: SBBC Student Data Authorization

The Youth F.O.R.C.E. program operated by the Crockett Foundation, Inc. is funded by the Children’s Services Council of Broward County (CSC). The CSC 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 CSC, for the purposes of: (1) enrolling students into CSC programs; (2) researching and evaluating the effectiveness of CSC 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 CSC 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 post-secondary 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.

ID different Consent

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 17: Social Security Collection Authorization Form

The Children’s Services Council (CSC) has implemented procedures to ensure the collection of Social Security Numbers (SSN) and uniform pseudo-SSNs in order to enable the agency to use information from other databases (school system, Department of Juvenile Justice, Department of Children and Families, etc.) to evaluate the impact of CSC-funded programs on rates of delinquency, abuse and neglect, school success, etc. New laws concerning the collection of SSNs have created another change that will require your cooperation. In order to ensure timely compliance with the law, you will need to begin to inform all of your program participants of the reason for the collection of SSNs, in writing beginning Jan. 31, 2008, using the following language.

The Children’s Services Council of Broward County (“CSC”) collects and uses the social security numbers of participants of CSC-funded programs and the parents/guardians of such participants so that CSC may collect and use data from other agencies for comparison purposes in order for CSC to track and measure the impact of CSC-funded programs. This also helps CSC with maintaining and improving successful programs and services. All individual information is safeguarded and will not be disclosed. CSC’s collection of social security numbers from its participants and the parents/guardians is critical for the performance of CSC’s duties and responsibilities as prescribed by law. Social security numbers collected by CSC shall not be used by CSC for any purpose other than the purpose provided in this written statement.”

ESPAÑOL:
"The Children’s Services Council of Broward County (CSC) recoge y utiliza los Social Security Numbers de los participantes de programas financiados por CSC y los padres / tutores de dichos participantes para que CSC pueda recoger y utilizar datos de otras agencias con fines de comparación en orden para que CSC rastree y mida el impacto de los programas financiados por CSC. Esto también ayuda a CSC a mantener y mejorar programas y servicios exitosos. Toda la información individual está protegida y no será divulgada. La recopilación de Social Security Numbers de CSC de sus participantes y los padres / tutores es fundamental para el funcionamiento de los deberes y responsabilidades de CSC según lo prescrito por la ley. Los Social Security Numbers recogido por CSC no seran utilizados por CSC para ningún otro propósito que no sea el previsto en esta declaración escrita.”

CREOLE:
"The Children’s Services Council of Broward County (CSC) kolekte epi itilize Social Security Numbers patisipan yo nan pwogram CSC finanse ak paran / gadyen nan patisipan sa yo pou CSC ka kolekte epi sèvi ak done ki soti nan lòt ajans pou rezon konpare nan lòd pou CSC pou swiv epi mezire enpak pwogram CSC finanse yo. Sa a ede CSC tou pou kenbe ak amelyore pwogram siksè ak sèvis yo. Tout enfòmasyon endividyèl yo pwoteje epi yo pap divilge. Koleksyon CSC nan Social Security Numbers nan patisipan li yo ak paran / gadyen yo se kritik pou pèfòmans nan responsablite CSC yo ak responsablite jan lalwa preskri. Social Security Numbers ki kolekte pa CSC pa dwe itilize pa CSC pou nenpòt ki rezon ki diferan de objektif yo bay nan deklarasyon sa a ekri. "

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 18: TOP® Consent Form

Your child has been chosen to participate in the Teen Outreach Program®, replicated at The CROCKETT FOUNDATION youth development program and owned by Wyman Center, Inc. (Wyman). During the time your child will spend in the Teen Outreach 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 and may take place off school grounds. The program promotes progress in school and avoidance of behaviors which may hinder your child's most successful growth and achievement.

Consent to Participate in the Teen Outreach Program®:
I, the undersigned, am the Parent or Legal Guardian of the child named below who is to participate in programs provided by The Crockett Foundation during the current school year. I am aware that there are potential hazards and risks involved in some programs. I am willingly allowing the child mentioned above to participate in all aspects of the program (including field trips and transportation) under the supervision of The Crockett Foundation staff. The CROCKETT FOUNDATION staff will accompany off site activities. I agree to hold harmless and indemnify the Crockett Foundation, its Board of Trustees, and/or its employees, agents, or lessors from any and all claims by myself, my teen, my heirs, my family, or my assigns.

Teen Outreach Consent *

I Consent
I DO NOT Consent

Consent to Use Photographs:
I give my consent to The CROCKETT FOUNDATION to use videos and/or photographs of my teen for brochures, to display in photo albums, in advertisements, or for other publicity purposes. If my teen’s photo is used, he/she will only be identified by their first name.

Teen Outreach Consent Photography *

I Consent
I DO NOT Consent

Consent to Participate in Surveys & Data Collection:
I give my consent for my child to complete surveys during their TOP® Club participation. Wyman Center, Inc. operates a secure environment to collect and store information from student participants in its Teen Outreach Program®. The online system also stores information about the TOP® services each student received.

Wyman collects the following types of information directly from TOP® participants through online surveys:

Opinions about their experience in TOP®
Demographics: Ethnicity/race, gender, most frequent guardian, parents’ education level
School records: Grade in school, absences, truancy, suspension, course failure, graduation and schooling plans
Health information: Pregnancy, parenting

I understand WYMAN and The CROCKETT FOUNDATION uses the participants’ responses to improve the Teen Outreach Program®. I understand that survey and data collection is voluntary and that my child may choose not to participate at any point in the process without risk of losing TOP® services. I am also aware my child will not be required to disclose more information than is reasonably necessary to participate in Teen Outreach Program® as a condition of participation. I am aware that survey responses may be shared with third parties to market the Teen Outreach Program® and to increase awareness and funding, but that your child’s identifying information will not be disclosed except in the case where online access is unavailable and therefore paper survey data is entered by a third party or employee under a strict non-disclosure of confidential information agreement. I also understand that the associated risks for my child to participate in this survey are minimal and will not exceed any discomfort that may be found in any daily life situations when answering routine survey questions.

Teen Outreach Consent Survey Data *

I Consent
I DO NOT Consent

Student Participant Name *

School *

Margate Middle School
New River Middle School
Pompano Beach Middle School
Silver Lakes Middle School
Somerset Prep Academy (North Lauderdale)

Student ID Number

Parent/Guardian Name *

Parent/Guardian Signature *

Clear Signature

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Section 19: 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 Friday, 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 *

Clear Signature

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Section 18 - Before & After School Child Care Program

This application is not complete until you complete the Before & After School Child Care (BASCC) program application using the link below. Incomplete applications will not be accepted.

https://www.browardschools.com/bcps-departments/strategy-innovation/before-and-after-school-child-care-bascc/applications

I completed and submitted the BASCC application.

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The youth program services offered through this application are centered on enrichment activities dedicated to academic support, STEM instruction, and positive youth development.

Section 1: Program Information

Section 2: Student Participation Information

Section 3: Parent / Guardian Information

Section 4: Family Background (if applicable)

Section 5: After-School Mode of Transportation

Section 6: Student Participant Medical Information

Section 7: Emergency Contacts

Section 8: Confidentiality of Records

Section 9: Field Trip Permission Slip

Section 10: Consent & Release

Section 11: Service Contract

Section 12: Statement of Child Rights

Section 13-A: Discipline Matrix

Section 13-B: Student Discipline Policy

Section 14: Extra-Curricular Activities Consent & Release

Section 15: Media Release Form

Section 16: SBBC Student Data Authorization

Section 17: Social Security Collection Authorization Form

Section 18: TOP® Consent Form

Section 19: Attendance Policy

Section 18 - Before & After School Child Care Program

Impact Reports

Certificate of Transparency