DO NOT COMPLETE THIS FORM UNLESS YOU ARE PREPARED TO PAY TODAY THE MINIMUM $50 DEPOSIT OR FULL PAYMENT OF $250.
West Oakland Site Registration - Level 2
Use this form to register for the program to be conducted at our West Oakland Site. Level 2 (Ages 8-10 and/or grades 3-5)
West Oakland Middle School
991 14th Street
Oakland, CA 94697
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 email@example.com to register your child.
Date Format: MM slash DD slash YYYY
Name and city of school where your child is enrolled.
Grade level for OFS will be based on the grade student will enter in Fall 2019.
What is the primary or native language spoken at home?
Does your child have a sibling(s) who currently participates, or has participated in the OFS program? Choose One
EMERGENCY CONTACT INFORMATION
In case of emergency, please contact:
Please list other adults who are authorized to pick up your child.
STUDENT MEDICAL INFORMATION
Does your child have health insurance? Choose One
If Yes above, please provide the name of the Health Insurance Carrier
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:
Please describe any developmental delay or physical impairment or if not applicable, indicate none.
Does your child currently have an IEP or 504 Plan?
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:
Does your child currently need or use medication prescribed by a doctor?
Is child currently in foster care?
Has child ever been in foster care?
Any children in the home ages 0-5? Choose One:
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.)
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.
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.
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:
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:
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.
Your Signature (Use Mouse, Touch Screen/Pad)
Mandatory Parent Orientation
Oakland Freedom Schools - Payment
What is the First and Last name on the credit/debit card being used for payment?