Application Checklist
Complete each page of this registration form. Your application will not be processed
if all pages are not complete.
Also be prepared to submit the following with your application:
Supporting Documents
Copy of your child’s IEP (Individualized Education Plan) or 504 Plan, if applicable.
Completed Creative Motivations Transportation Authorization (Page 5).
Program Dates & Hours:
August 23, 2021-June 3, 2021
2:30p.m.-6p.m. (afterschool) 8a.m.-6p.m. (Teacher Workday)
Creative Motivations, INC. will operate on Guilford County Schools schedule and will offer full-day programming on Teacher Workdays from 8:00a.m.-6:00p.m. Pick-up for your student begins at 5:45pm. If you decide to withdraw your child from Creative Motivations after-school
program, at least 2 weeks advanced written notice is required. Failure to do this may result in the inability to participate in future programs at Creative Motivations, INC.
Participant Information
Last name: _____________________________ First name: __________________________
Date of Birth: ___________ Gender: _________ Current Grade Level: ___________________
School Attending: _________________________________
Home Address: _______________________________________________________________
City:__________________ State/Province: _____________ Postal/Zip Code: ______________
Parent/Guardian Information
Parent/Guardian Name: _____________________________________________
Cell Phone: _______________ Day Phone: ____________________
Email: _____________________________________________________________
Emergency Contact –(should be someone other than you)
Contact
Name:______________________________
Relationship:________________
Phone: _________________
Contact
Name:______________________________
Relationship:________________
Phone: _________________
Medical Background:
Does your child have an IEP or 504? ☐YES☐NO If yes, please provide a copy of accommodations sheet.
Please specify any health problems your child may have: ____________________________
Please specify any medications your child needs: __________________________________
Preferred Medical Provider: ___________________________________________________
Doctor’s Name: ____________________________ Tel: ______________________
Address: ____________________________________________________________
Insurance Provider: __________________________________________________________
Policy #: _____________________________________________________________
Primary Policyholder: ___________________________________________________
Food allergies/sensitivities: _____________________________________________________
Note: If you will be sending your child’s lunch/snack, please be sure that your child’s lunch/snack is clearly marked with your child’s first and last name. Refrigerators will be available for your child to store his/her lunch/snack. Glass bottles/containers are not allowed.
** Creative Motivations, Inc. is taking all necessary precautions in light of the COVID-19 pandemic. All persons are required to wear a mask upon entry to our facility. If your child is sick or having any cold/flu-
like symptoms, please KEEP THEM HOME.**
I, _________________________________ give permission to Creative Motivations, INC. to (Parent/Guardian name)
seek medical attention for my child in the event of an emergency.
Are there any religious beliefs that my affect treatment? _______________________________
____________________________________________________________________________
Signature of Parent/Guardian: _________________________________ Date: ___________
(by signing above, I give my consent to Creative Motivations, INC. to obtain any medical treatment for my child that may be necessary during an emergency)
Payment Information:
After-School Enrollment Fee: $35 Fee: $65/week (2:30p.m.-6p.m.)
Teacher Workdays: $35 per day($45 per day for early drop-off at 7:30a.m.) (8a.m.-6p.m.)
*Payments are due one week in advance from the first week that the program begins.
*Please let us know if you will need an early drop-off
**All fees are due on Thursday and may be paid by credit card, money order, check or Cash App. Make checks and money orders payable to Creative Motivations. Cash App: $WllCasterlow
Parent Statement:
I understand that by signing this application that I am agreeing to the following:
1. The above named child can safely participate in the activities provided by the Creative Motivations.
2. Creative Motivations, INC. has the right to remove students from the program who are not complying with regulations as it pertains to behavior.
a. Creative Motivations, INC. will not be held responsible in the event that my child engages in inappropriate conduct including but not limited to disruptive or
volatile behavior in or out of our program, any behavior not permitted under Creative Motivations and regulations, etc.
3. Creative Motivations, Inc. will not be held liable for any damages whatsoever, any legal expenses, or costs which may arise from any claim as a result of the death of the above child arising from sickness or of injury which said child might have contracted or
sustained during time at Creative Motivations, INC., except where such injury, illness or damage is a result of the unlawful and intentional negligence of the program or an employee of the program.
4. I will not hold the owners or employees of Creative Motivations, Inc. responsible for any accident that may occur while my child is in transit, except where such injury, illness or damage is a result of the unlawful and intentional negligence of Creative Motivations, INC. or an employee of the organization.
a. CREATIVE MOTIVATIONS, INC. WILL TAKE EVERY POSSIBLE PRECAUTION TO SAFEGUARD YOUR CHILD; HOWEVER, WE DO NOT HOLD OURSELVES
RESPONSIBLE FOR ANY ACCIDENTS WHICH MAY OCCUR WHILE THE CHILD IS IN OUR CARE WHILE ATTENDING OUR PROGRAM.
~~For the safety of both guests and staff, firearms are not allowed on Creative Motivations premises at any time. Closed circuit television and audio monitoring are in effect on
premises~~
Note: Creative Motivations, INC. will take photos and/or record students during activities.
I DO NOT authorize Creative Motivations, INC. to photograph and/or videotape my child for educational and/or promotional purposes. __________ (Initial)
By signing below, I agree to the policy and fee statements listed and attest that all information provided is correct to the best of my knowledge.
Parent/Guardian Signature: __________________________________ Date: ______________
Transportation Authorization
☐ My child will not need transportation
I ___________________________ (parent name), give Creative Motivations, INC. permission to transport my student, ___________________________________ (student name) from
___________________________________ (school) to Creative Motivations, INC., located at 114 S. Westgate Dr., Ste. D. I understand that if my child will not be attending the Creative Motivations After-School Program, that I am required to contact the site director by 1:00 p.m. on or before the date my student will not be attending.
Transportation Procedures:
Students are picked up from their school where they will quietly board the bus We will mark the student absent or present on the bus roster
Any students that do no board the bus, verification will be obtained from the school regarding the whereabouts of the student.
If a student is disruptive on the bus, Creative Motivations reserves the right to disallow or suspend the student from riding.
Parent/Guardian Signature: __________________________________ Date: ______________
After-School Offerings
Creative Motivations, INC. offers activities that serve to enhance learning and promote overall growth for all students.
● Homework Assistance: Through homework assistance, we will help students review and practice what they have learned in class, prepare for the next day, and use their resources. We will also help students learn good study habits and positive attitudes toward learning.
● Hands-On Learning: We are focused on skill training and entrepreneurship through technology. Information technology can help students with multitasking skills that can be used throughout life. Youth love technology and this can be used as a tool to motivate learning.
● Mentorship:
The goal of our mentorship program is to help break down barriers and create opportunities for success. We will provide youth with positive guidance and support as they journey toward adulthood.● Socialization:
We understand that socialization is an important part of developing social skills such as empathy, sharing, and leadership. We will help your student with self-regulation, self-identity, self-esteem, empowerment, and appropriate social roles.● Family Nights:
Creative Motivations, INC. is a family oriented organization and it isimportant that we provide opportunities for our parents to actively participate in the growth and development of their student.
● Arts & Crafts:
Arts and crafts are great ways for students to improve coordination and fine motor skills, as well as provide a way of expression. As our students enjoy expressing themselves through arts and crafts, we are encouraging creativity and building self-esteem.● Games:
Playing games allows us to continue to work with our students on appropriate social skills such as sharing, social problem solving, managing emotions, and communication.We offer scholarship opportunities on after-school care for children in Kindergarten through Middle School.
All-day programs are available when Guilford County Schools are closed for teacher workdays.
After-school Hours: Monday-Friday 2:30pm – 6:00pm Teacher Workday Hours: 8:00am – 6:00pm
After-school, holidays and breaks follow the Guilford County School schedule.
Please contact 336.992.2292 with questions.
Creative Motivations, INC. Waiver
Release and Indemnity Agreement:I understand that participating in the class (es) or program (s) selected involves risk of injury. These risks include inclement weather, accidents while traveling, equipment problems or failures, contacts with actions of other participants, slips/trips/falls, and musculoskeletal injuries, among others. I choose for myself or for my child to participate in the selected programs despite the risks. By signing the registration form, I acknowledge all risks of injury, illness and death and affirm that I have assumed all responsibility of injury, illness or death in any way connected with participation in the program. I also agree for myself and for any child participant to follow all rules and procedures for the program and to follow reasonable instructions of the teachers and supervisors of the program. In return for the opportunity to participate in this program, I agree for myself and for my heirs, assigns, executors and administrators to release, acquit, waive and forever discharge any legal rights I may have to seek payment or relief of any kind from the Creative Motivations, INC., its officers, employees, agents or its volunteers for injury, illness, death or property loss resulting from this program.
If I am registering a child for a program, I agree that I am a parent, legal guardian, or am otherwise responsible for the child whose application I am submitting and that I release, waive, and discharge any legal rights that I may request on behalf of the child participant in the program. I also agree not to sue Creative Motivations, INC., its officers, employees or agents and agree to indemnify Creative Motivations, INC. for all claims, damages, losses, or expenses, including attorney’s fees, if a suit is filed concerning an injury, illness or death to me or my child resulting from participation in the program. Permission is given for any emergency medical treatment which might become necessary and I agree to be responsible for the expense of medical treatment or service.
Image Release:I, the undersigned, hereby consent to allow the exclusive use of, and relinquish all rights to, photographs, recordings and reproductions in any manner (including but not limited to the use of photos, video and audiotapes) of the likeness, voice, and/or activities of the participant and further authorize Creative Motivations, INC. of Greensboro, its agents or assigns, to make unlimited use of such reproductions, including but not limited to print and/or electronically, broadcasting of the reproduction over radio, television, and on the internet with or without your name for any lawful purpose. I acknowledge that no compensation will be provided for such use by the Creative Motivations, INC. I understand that this Release shall remain in effect unless a subsequent written notification is provided to the Creative
Motivations, INC.
☐ I do not give photo/video permission.
Non-Discrimination Policy:It is the policy of the Creative Motivations, INC. that the Creative Motivations, INC. will not discriminate on the basis of sex, race, gender, color, ethnicity, national origin, age, familial status, marital status, military status, political affiliation, religion, physical or mental disability, genetic information, sexual
orientation, gender expression, or gender identity in authorizing or making available the use of Creative Motivations, INC. facilities or in the delivery of its programs, services or activities.
Creative Motivations, INC.recommends that all participants complete an annual physical and consult a health care professional to assess their ability to participate in athletic activities.
