510.912.9232
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oaklandfreedomschool@gmail.com | La'Cole Martin
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OFS 2019
2019 OFS INFORMATION
East Oakland Registration – Level 1
East Oakland Registration – Level 2
East Oakland Registration – Level 3
West Oakland Registration – Level 1
West Oakland Registration – Level 2
West Oakland Registration – Level 3
McClymonds Registration – Level 4
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ABOUT OFS
OFS 2019
2019 OFS INFORMATION
East Oakland Registration – Level 1
East Oakland Registration – Level 2
East Oakland Registration – Level 3
West Oakland Registration – Level 1
West Oakland Registration – Level 2
West Oakland Registration – Level 3
McClymonds Registration – Level 4
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DONATIONS
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East Oakland Registration – Level 1
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East Oakland Registration – Level 1
East Oakland Registration – Level 1
f1mktsol
2019-04-01T15:21:25-08:00
IMPORTANT!
DO NOT COMPLETE THIS FORM UNLESS YOU ARE PREPARED TO PAY TODAY THE MINIMUM $50 DEPOSIT OR FULL PAYMENT OF $250.
East Oakland Site Registration - Level 1
Use this form to register for the program to be conducted at the East Oakland Site.
Level 1 (Ages 5-7 and/or grades K-2, student must be 5 by June 9, 2019)
LOCATION: Markham Elementary School, 7220 Krause Ave, Oakland, CA 94605
PLEASE NOTE: There is a $50 non-refundable donation fee to register for this program. You will need a valid credit or debit card to complete this application. If you are unable to register and make a payment online, please contact the Program Director, La’Cole Martin, via phone 510-912-9232 or via email at oaklandfreedomshool@gmail.com to register your child.
Today's Date
*
Date Format: MM slash DD slash YYYY
STUDENT INFORMATION
Student's Name
*
First
Last
Current Age
*
Date of Birth
*
MM
DD
YYYY
Race/Ethnicity
*
Choose One
African American/Black, non-Latino
Native American/Indian or Alaska Native
Asian American
Native Hawaiian or Pacific Islander
Latino/Hispanic
European American/White, non-Latino
Mixed Heritage
Gender
*
Choose One
Male
Female
Current School
*
Name and city of school where your child is enrolled.
School Grade
*
Grade level for OFS will be based on the grade student will enter in Fall 2019.
Primary Language
*
What is the primary or native language spoken at home?
Siblings at OFS
*
Does your child have a sibling(s) who currently participates, or has participated in the OFS program? Choose One
Yes
No
If Yes above, their names please
Has your child attended OFS before?
*
Yes
No
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name
*
First
Last
Relationship to Child
*
Choose One
Father
Mother
Legal Guardian
Foster Parent
Grand Parent
Student's Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
EMERGENCY CONTACT INFORMATION
In case of emergency, please contact:
(1) Name
*
First
Last
Relationship to Student
*
Phone
*
(2) Name
First
Last
Relationship to Student
Phone
Authorized Adults
Please list other adults who are authorized to pick up your child.
Name
Relationship
Phone
STUDENT MEDICAL INFORMATION
Medical Insurance
*
Does your child have health insurance? Choose One
Yes
No
Health Insurance Carrier
If Yes above, please provide the name of the Health Insurance Carrier
Medical Conditions
*
Has a doctor or health professional ever informed you that your child has any of the following medical conditions or disabilities? Check all that apply:
Allergies or Allergic Reactions
Asthma
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Autism
Behavior or conduct problems
Bone, joint, or muscle problems
Cystic Fibrosis
Diabetes
Depression or anxiety problems
Hearing Problems
Obesity
Seizures
Sickle Cell Disease
Vision Problems
No Medical Conditions
Impairments
*
Please describe any developmental delay or physical impairment or if not applicable, indicate none.
Educational Support
*
Does your child currently have an IEP or 504 Plan?
Yes
No
If "Yes" Above
Note: If yes, additional paperwork may be requested so that our staff is able to better support your child academically during the summer months. Please write a brief description of your child's needs:
Medications
*
Does your child currently need or use medication prescribed by a doctor?
Yes
No
If Yes above, please list all medication(s). If none, indicate none.
*
Dietary Information
*
Vegetarian
Vegan
Food Allegeries
None
If Food Allergies above, please list
T-SHIRT SIZE
Choose One:
*
Child - Small
Child - Medium
Child - Large
Adult - Small
Adult - Medium
Adult - Large
Adult - Extra Large
Adult - XX-Large
FOSTER CARE
Current Foster Care
*
Is child currently in foster care?
Yes
No
Former Foster Care
*
Has child ever been in foster care?
Yes
No
EARLY CHILDHOOD
Early Childhood
*
Any children in the home ages 0-5? Choose One:
Yes
No
Parent/Guardian Consent
I give permission to Oakland Freedom Schools ("OFS") and its designees to collect and record data on my child(ren). This data gathering may include, but is not restricted to, the following: * Surveys and/or interviews about his/her/their knowledge, attitudes, skills and behaviors in regard to his/her/their academic development such as motivation to read; nonacademic development such as leadership and conflict resolution skills; and overall satisfaction with the OFS program. * Academic assessments and school data from report cards. These will be collected minimally twice; either shortly before the program begins, during the program, or shortly after the program ends. I understand that the the purposes of these surveys and interviews are to document the impact of the Oakland Freedom Schools program on its participants and to identify areas for improvement. I also understand that that this information will remain private, and that only my child(ren)'s site director(s) and research assistants will be able to look at his/her responses. I also understand that my child(ren)'s responses will be automatically grouped together with the responses of other OFS sites for any public presentations of findings, and that my child(ren) will not be individually linked to his/her/their responses. In addition, I understand I can take back my permission at any time. Additionally, I give permission for my child(ren) named above, to participate in all Oakland Freedom Schools field trips including walking trips to parks, libraries, and local businesses. I give OFS staff permission to transport my child in cars, charter, and public transit (e.g. AC Transit buses, BART trains, and etc.)
Consent Agree/Disagree With Above
*
Choose One
Agree
Disagree
Oakland Freedom Schools Release of Liability
I understand the nature of the OFS summer program and that participation is voluntary. I understand that OFS is not responsible for loss, damage, illness, or injury to person or property as a result of participation in the program. I hereby release and discharge Oakland Freedom Schools and its staff and volunteers from any and all claims for injury, illness, death, loss or damage as a result of the summer enrichment program activities.
Release of Liability Agree/Disagree With Above
*
Choose One
Agree
Disagree
Oakland Freedom Schools Media Release
During your child’s attendance in OFS s/he may participate in an activity that is being photographed or videotaped; these photographs/video recordings may be used for promotional purposes. I hereby authorize and irrevocably grant to the Oakland Freedom Schools and its affiliates, licensees, agents and assigns the unrestricted right to use and publish any part of the information that I have given to OFS and the right to record my name, voice, appearance, likeness and comments on film, videotape, audiotape, still photographs, print and any other media now known or hereafter invented. I acknowledge that OFS shall own all right, title and interest in and to this media. I further agree that OFS may cause all or parts of this media to be used for any and all publications, exhibitions, public displays, editorials, advertising or other purposes. I waive any inspection or approval of the media or any advertising or publicity in which my name, voice, appearance, likeness, narrative, or comments might appear. I expressly release and agree to hold harmless OFS and its agents, employees, licensees and assigns from and against any and all claims including, but not limited to, invasion of privacy that I might ever have in any way relating to my interview or its use.
Media Release Agree/Disagree With Above
*
Choose One
Agree
Disagree
SCHOLARSHIP
If you are in need of a scholarship for your child to attend Oakland Freedom Schools, please complete this section. Write a statement detailing your situation and why you are requesting a scholarship:
HOUSEHOLD INCOME
Household Income
*
Choose One:
$26,750 or Below
$44,600 or Below
$64,400 or Below
$89,200 or Below
More than $89,200
How many people in household are support by this income?
How many children (ages 5-13) are you enrolling in Oakland Freedom Schools?
Does your child receive free or reduced lunch at their current school?
Choose One:
Yes
No
Scholarship Request Amount
Note: Scholarship applicants will be notified of their award status two weeks after registering. All remaining balances will be due by the Parent Orientation on June 6th, 2019. Choose One:
$100 Scholarship - $150 Due
$200 Scholarship - No Remaining Balance Due
Parent Closing Statement
I hereby certify that the statements in this application are correct and true. I understand that my child(ren)’s enrollment as a OFS student is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by Oakland Freedom Schools.
Signature
*
Your Signature (Use Mouse, Touch Screen/Pad)
Mandatory Parent Orientation
To secure your child’s spot this summer, a parent/guardian (or other adult with authorization) must attend orientation on Thursday, June 6th from 5:30-7pm. Will you or someone on your behalf attend the Parent Orientation?
*
Choose One:
Yes
No
Name
*
What is the First and Last name on the credit/debit card being used for payment?
First
Last
Oakland Freedom Schools - Payment
Payment
*
Choose One:
Full donation fee of $250.00.
Registration donation fee of $50.00 (non-refundable) balance due by June 6th.