2022 SUMMER 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 Enrichment Program STUDENT INFORMATIONStudent* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code PARENT / GUARDIAN CONSENT FORMDear 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.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.*Consent* I specifically authorize the following:* Conducting of interviews, tests and questionnaires for student program evaluation purposes. 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. Referrals to other agencies for specific services (e.g. health, public assistance, 4th and Goal Mentoring counseling and or psychological testing). Transportation of my child (whether by public or private transportation, including by bus, taxi, or automobile) in field trips, appointments, meetings, and other activities. Participation in services specified in my child's service plan, such as counseling, tutoring, cultural enrichment, and/ or recreational activities. 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. 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. 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. Consent* 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.*Consent* I agree that the services provided by CIS of Lake County are full and adequate consideration for this waiver.*Consent* 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:Student Name* First Last Signature of Parent/Guardian* First Last Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent Email Address* Phone*
