HIGH SCHOOL PROGRAM APPLICATION

Please completely fill out this registration form for your child to join Communities in Schools of East Chicago/Lake County’s program. High School credit will not be given, unless your child attends ALL sessions regularly.

Which Course Are You Enrolling In?*
- Freshman Academy
- Integrated Math
- Life Skills
- Youth P.L.U.S.
STUDENT INFORMATION
Student School ID #*
Student*
First Last
Gender*
Race*
Date of Birth*
MM slash DD slash YYYY
Grade*
Cumulative GPA*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Special Needs (If Applicable)*
- Physical
- Educational
- IEP
- Limited Eng. Proficiency
- N/A
Parent Contact Information
Primary Contact*
- Mother
- Father
Mother/Guardian Name*
First Last
Home Phone*
Work Phone*
Cell Phone*
Mother/Guardian Email*
Mother/Guardian Address*
Street Address City State / Province / Region ZIP / Postal Code
Father/Guardian Name*
First Last
Home Phone*
Work Phone*
Cell Phone*
Father/Guardian Email*
Father/Guardian Address*
Street Address City State / Province / Region ZIP / Postal Code
Emergency Contacts
Contact #1
Contact #1 Name*
First Last
Relationship to Student*
Phone*
Phone Type #1*
- Home
- Mobile
Contact #2
Contact #2*
First Last
Relationship to Student*
Phone*
Phone Type #1*
- Home
- Mobile
Pick Up Policy
Pick Up Policy*
- My child has been instructed to walk home after the Program.
- I will take responsibility to have my child picked up promptly after the program.
- My child does have permission to ride the School City of East Chicago bus home
Permission for Program Participation*
I give permission for my child to participate in the Communities in Schools of East Chicago/Lake County Program.
Media Release: During the course of the program, students may be photographed to promote and publicize the program.*
I give permission for my child to be photographed to promote and publicize the program
Authorization to Treat a Minor/ Release/ Health Information
I/we, the parent(s) or legal guardian(s) of the above named minor, hereby give my/our permission for my/our child to participate in the CISEC-LC program and activities, including transportation involved for his/her participation in off-campus activities, and absolve CISEC-LC from liability to me/us and my/our children because of illness or injury to my/our child or loss of his/her property resulting from such participation. Further, I/we hereby assume all risk associated with my/our child’s participation the CISEC-LC program and activities, and agree to hold harmless CISEC-LC, its employees, agents, representatives, and volunteers from any and all liability, actions, course of actions, debts, claims or demands of any kind and nature whatsoever which may arise by or in connection my/our child’s participation in any activity related to CISEC-LC program.

In event of medical emergency, I/we hereby authorize CISEC-LC leadership to exercise its discretion in obtaining and/or providing medical attention for my/our child. I/we hereby assume full responsibility for all financial obligations arising from transporting my/our child to a medical facility, and for all other expenses related to obtaining and/or providing medical attention for my/our child. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is give to provide authority and release to obtain or render care which CISEC-LC leadership, in the exercise of its best judgment, may deem advisable. It is understood that effort will be made to contact the undersigned prior to rendering treatment to the patient, but that treatment will not be withheld if the undersigned cannot be reached.
Minor's Name*
First Last
School*
Date of Birth*
MM slash DD slash YYYY
Height*
Weight*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Name of Health Insurance Co*
Policy #*
Name of Physician*
Phone*
Do you have any of the following? Check all that apply and explain in the next box.*
- Food Allergies
- Medication Allergies
- Other Allergies
- Asthma
- Diabetes
- Epilepsy
- N/A
If you checked any above, please explain type and severity.*
Do you take any medication(s) on a regular, on-going basis? If yes, please list.*
Please list any other health condition or medical information that may need to be disclosed to medical professionals before treatment.*
Consent*
I hereby certify that the forgoing is true & correct, and that I understand and agree to all provisions described herein.*
Mother/Legal Guardian*
First Last
Primary Phone*
Father/Legal Guardian*
First Last
Primary Phone*
Person other than parent(s)/guardian(s) to be called in case of emergency:
Other Guardian Name*
First Last
Phone*
Relationship to Child*
PARENT/GUARDIAN CONSENT FORM
Dear Parent or Guardian:

Your child has been referred to Communities In Schools of Lake County as someone who would benefit from CIS services. Your permission is needed for your child's general participation in Communities In Schools activities designed to increase school attendance, improve learning, encourage personal and social development and (in higher grades) increase employability and eligibility for college.

Among the services offered by CIS are counseling services, recreational activities, virtual/in-person academic and enrichment programs, linkages to health and human services, field trips, career exploration, and assistance in preparing for college. In order for your child to participate, your authorization and agreement the terms of this consent form, as evidenced by checking the boxes below, is required.
Student*
First Last
School*
Student ID #*
Consent*
I hereby grant permission for my child to participate in Communities In Schools of Lake County and all CIS services, until supports are no longer needed or until I notify CIS of Lake County, in writing of my desire to withdraw my student from CIS services.*
Authorization*
I specifically authorize the following:*
1. Conducting of interviews, tests and questionnaires for student program evaluation purposes.
2. Release of confidential information (i.e. access to the student’s records, including grades, lest scores, attendance or disciplinary records, interviews, etc.; access to other financial, medical, or public assistance information by appropriate agencies) to qualified professional CIS staff as needed. Subject to federal and state law, this information will be maintained in a confidential matter.
3. Referrals to other agencies for specific services (e.g. health, public assistance, 4th and Goal Mentoring counseling and or psychological testing).
4. Transportation of my child (whether by public or private transportation, including by bus, taxi, or automobile) in field trips, appointments, meetings, and other activities.
5. Participation in services specified in my child's service plan, such as counseling, tutoring, cultural enrichment, and/ or recreational activities.
6. Emergency medical or dental treatment from a local hospital or by any licensed practitioner or dentist the event of illness, accident tor other emergency, if I am unable to be reached in a timely manner.
7. Participation in photos, interviews and/or videotaping pertaining to the program and use of any of these by Communities In Schools or advertising, training and / or public relations purpose.
8. I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS of Lake County staff, in writing, except that prior consent will still apply to the extent that agencies have already taken action in reliance of it.
Liable*
I further state that I will not hold Communities In Schools of Lake County, Inc. or any other authorized work site, organization or agency, liable for medical and/ or surgical treatment in case of illness, accident or any other emergency situation.*
Waiver*
I agree that the services provided by CIS of Lake County are full and adequate consideration for this waiver.*
Participation*
To further my child's academic, personal and vocational development, I will participate in at least two parent/ guardian conferences per year to discuss my child's progress (either through a home visit or school visit).*
Please indicate any activities in which you do not wish your child to participate:*

HIGH SCHOOL PROGRAM APPLICATION

STUDENT INFORMATION

Parent Contact Information

Emergency Contacts

Pick Up Policy

Authorization to Treat a Minor/ Release/ Health Information

PARENT/GUARDIAN CONSENT FORM