Register for YouthQuest at International Academy of Flint K-12

YouthQuest at International Academy of Flint 2020-21 School Year Program

in partnership with

The 2020-21 school year program is for students in grades K-12 at the International Academy of Flint. This registration form is for International Academy of Flint students only.

One registration form per student must be completed by parent/legal guardian.

Space is limited in the program. Children will be registered on a first come, first served basis. Once enrollment is full, a waiting list will be created.

Student Last Name *

Student First Name *

Student Middle Initial

Student Date of Birth (MM/DD/YYYY) *

Student Age (Years)

Student Shirt Size *

Student Gender

Grade *

Homeroom Teacher Name *

Student will Attend YouthQuest *

In person (In-person program will begin when International Academy of Flint begins face-to-face instruction)

Remotely

YouthQuest Program Preference (select one) *

Students will be able to switch between Fall, Winter and Spring sessions, but to start the school year, please select one of the choices below.

Traditional YouthQuest (Monday-Thursday)

YQ Clubhouse (Allows for selecting specific interest clubs Monday-Friday, such as Kettering robotics, CrimFit Sports Program and other partner activities)

Eligible for Free/Reduced Lunch *

Yes

Address *

Country

City

State

Zip code

Parent/Guardian Name *

Student Lives with *

Yes

Primary Phone Number *

Secondary Phone Number

Sign me up for the monthly YouthQuest eNewsletter - Afterschool Download

Yes

Parent/Guardian Name

Student Lives with

Yes

Primary Phone Number

Secondary Phone Number

Sign me up for the monthly YouthQuest eNewsletter - Afterschool Download

Yes

Additional Emergency Contact Name

(Allowed to pick up child)

Cell Phone

Work Phone

Relationship to Student

Additional Emergency Contact Name

(Allowed to pick up child)

Cell Phone

Work Phone

Relationship to Student

Name(s) of Sibling(s) Registered for YouthQuest

My child may NOT be released to the following individual(s)

Medical Concerns, Allergies, Medications, Dietary or Other Special Needs:

Parent/Legal Guardian Consent *

	Yes	No
Does your child have emergency medication at the school? If yes, please list medication(s) above.
May staff administer emergency medication it if necessary?
Is your child’s medical form updated and on file with the school?
Do you give YouthQuest permission to access your child’s student records?
Are there activities your child should NOT participate in? If yes, please list below.
Do you give permission for your child to attend virtual field trips (if applicable)? (Permission Slip for all Trips)
Do you give permission for your child to attend field trips via bus transportation (if applicable)? (Permission Slip for All Trips)
May the programs photograph, record, videotape, and/or interview your child for promotion with the understanding this may be used in various media outlets (e.g., Facebook, Twitter, website, advertisements)?
May the staff perform general first aid if necessary?
Do you allow staff to apply Bug Spray to your child?
Do you allow staff to apply Sun Screen to your child?
My child is in good health and free from communicable disease.
My child is up to date on their immunizations and a copy of their immunization record is on file with the school.
I have received a copy of the parent hand book.
I am aware there is a licensing notebook available for me to see at the school.

Activities your child should NOT participate in:

Waiver and Release of Liability

I hereby certify that by completing and signing this form, I give my approval and permission for the child/children listed below to participate in Flint Community Education Initiative activities provided by the Crim Fitness Foundation, International Academy of Flint, YouthQuest, whose Programs are administered by the Flint and Genesee Chamber of Commerce, as well as by other community partners as convened by the Crim Fitness Foundation (the Programs). I understand my child’s/children’s participation in the Programs is voluntary and subjects him/her to the possibility of physical injury (which could be minimal, serious, and/or result in death) and loss of or damage to my property (Risks). Accordingly, I do hereby waive, release, absolve, indemnify and agree to defend and hold harmless Crim Fitness Foundation, the International Academy of Flint, YouthQuest, the Flint and Genesee Chamber of Commerce and their partners, officers, directors, employees, agents, volunteers, organizers, sponsors, and contractors other participants, including any other persons or entities transporting myself or my child or children (the Releasees) from any claim, demand, loss, liability, damages, including attorney fees and costs whatsoever arising from, related to, or resulting from these Risks, including those caused by the negligent acts or omissions of any or all of the Releasees occasioned by their participation in Community Education activities.

I attest and certify that my child or children is/are physically fit to compete safely, and I have not been advised otherwise by a health care professional. As between each of the Releasees and me, I will be solely responsible for any and all medical and related bills that my child/children may incur because of any injury, as well as costs related to loss or damage to my property, that my child/children may sustain as a result of his/her participation in any Flint Community Education Initiative Program, including those sustained on the premises where any Flint Community Education Program is conducted and while he/she is traveling to and from such premises, regardless of the location or mode of transportation. This agreement shall be binding on my estate, heirs, executors, administrators, successors, and assigns, as well as any other party asserting a claim on my behalf or on behalf of my estate.

I understand that the Programs may use ethnic background and data supplied on the International Academy of Flint meal application for their records, that my child’s teachers may share attendance and grade information, that Program employees, agents and volunteers may gather information about my child/children and that all this information may be shared with non-Program entities for evaluation purposes. Health information on file with the school may be released as needed in order to secure emergency medical treatment.

Behavior Expectations

It is the goal of Flint Community Education Initiative, YouthQuest, Crim Fitness Foundation and their partners to provide both a physically and emotionally safe environment for all program participants. With this in mind, each Program participant is required to follow the International Academy of Flint Code for Student Conduct as distributed to all International Academy of Flint students as well as provided on the iaf.sabis.net webpage and on file at each school in order to ensure that all Program participants strive to meet behavior expectations.

I will attend parent/family events and communicate with staff as necessary to address my child’s needs.

All out of school time programs are provided in partnership with International Academy of Flint. The International Academy of Flint Code for Student Conduct (Code) has been prepared as a service to all students, parents, and faculty of the International Academy of Flint. International Academy of Flint has authorized these policies and procedures to provide the standards and structure necessary to foster that safe educational environment in which students can learn as they mature mentally, physically, emotionally and socially in the International Academy of Flint. All policies, regulations, definitions, and procedures have been prepared to comply with the laws of the State of Michigan and of the United States to the best of our understanding, regarding the disciplining of general education/special education students. All parents, students, and faculty are expected to become familiar with the contents of this Code. I understand that if I do not follow the rules of conduct, I may be asked to leave or not allowed back for Programs.

The Flint Community Education Initiative will use the information on this form the entirety of Summer 2020. If any information on this form changes, it is the responsibility of the parent or legal guardian to notify the Crim Fitness Foundation Community Education Staff.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Digital Signature of Parent or Legal Guardian *

Reset Signature

Signature is required.

Please contact YouthQuest at (810) 600-1422 with any questions.

YouthQuest is a no-cost after school initiative operated by the Flint & Genesee Chamber of Commerce through the generous support of the Charles Stewart Mott Foundation and others.

YouthQuest International Academy of Flint

YouthQuest at International Academy of Flint 2020-21 School Year Program

YouthQuest
International Academy of Flint