Completion of application does not guarantee enrollment
Oceanside Unified School District ASES Program
Membership Application
July 1, 2021 – June 30, 2022
______________________________ ___________________
____________________________________Child’s First Name Middle Name Child’s Last Name
______/______/______ ____________ ___________ ____________ ______Yes or No____________
Birth Date Age Male Female Military Dependent
_____________________________________________________________________________ ________________
Child’s School Grade
____________________________________________________ ______________________________ _________________
Home Address City Zip Code
(_________)___________________________________ _______________________________________________________
Home Phone Number Parent E-mail Address
____________________________ ____________________________ (__________)_______________________________
Father/Guardian First Name Father/Guardian Last Name Father/Guardian Cell Phone Number ___________________________________________________________ (__________)_______________________________
Father/Guardian Employer Father/Guardian Work Phone & Extension ____________________________ ____________________________ (__________)_______________________________
Mother/Guardian First Name Mother/Guardian Last Name Mother/Guardian Cell Phone Number ___________________________________________________________ (__________)_______________________________
Mother/Guardian Employer Mother/Guardian Work Phone & Extension Emergency Contacts: (Please remember to update emergency contacts if they change)
___________________________________________________________ (__________)________________________________
Name of Emergency Contact #1 (other than parent) Emergency Phone Number
___________________________________________________________ (__________)________________________________
Name of Emergency Contact #2 (other than parent) Emergency Phone Number
Special Education Services: Special Ed (IEP) __________ 504-Plan__________ Has a 1:1 Aide per an IEP ________
If yes, list any information that may assist staff in supporting your child’s after school activities:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Permission for After School Program Staff to Access Report Cards: YES or NO MEDICAL INFORMATION: Medical Conditions, Allergies, Special Needs, List All Medications
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
________________________________
___________________________________________________________
Parent/Guardian Signature Date
Office Use Only ASES Original Intake Date____/_____
City Span # ______________________
ASES Provider: __________________
SSID#_____________________________
Student ID # Media Release:
YES or NO
Oceanside Unified School District ASES Program
PICK UP POLICY
2021/2022
_______1. As the parent of an ASES Member enrolled in the After School Program, I
understand it is my responsibility to pick up my child at the end of the program from the designated student pick-up area.
_______2. I will contact the Site Director immediately if I know I will be late picking up my child.
_______3. I understand I am responsible for picking up my child at the designated time on a regular basis.
_______4. I understand only the adults who are listed under the Emergency Contacts are permitted to pick up my child from the ASES Program.
I have read the Pick-Up Policy and I understand what is expected of me. I understand if I am repeatedly late in picking up my child, he/she will be dropped from the ASES
Program.
__________________________________________________ ______________________________
Parent/Guardian Signature Date
Oceanside Unified School District ASES Program - 2021/2022
STUDENT MEMBER-PARENT PROGRAM AGREEMENT It is important for your child to understand what is expected from him/her while participating in the ASES Program at their Oceanside Unified School. Equally important is for you as the parent to understand and discuss these expectations with your child.
Please review each statement with your child and have him/her initial and sign below:
_______1. I choose to be an “active” member of the ASES Program, and I must attend the entire program unless noted on the Early Release Form. The ASES Program runs a minimum of 3 hours per day.
_______2. As a member of the ASES Program, I will follow the Standards for Student Behavior as outlined in the Oceanside Unified School District Student/Parent Handbook.
_______3. As a member of the ASES Program, I will scan in with my membership card at the
designated program area immediately after the last school bell rings each day and I will scan out with my membership card each day before I leave.
_______4. I understand there is a consequence for any inappropriate action of behavior during the ASES Program hours.
_______5. I understand it is a privilege to be a member of the ASES Program and I will conduct myself in an appropriate manner.
_____________________________________________________
Print Student Member Name
_____________________________________________________ _____________________________
Student Member Signature Date
I have reviewed this agreement with my child. My child and I choose to participate in the ASES Program and understand what is expected of him/her.
______________________________________________ ________________________
Parent/Guardian Signature Date
Student Accommodations/Supports
Please use this form to indicate which accommodations/supports benefit this student in the classroom setting. These can be accommodations/supports as outlined in an IEP or 504 plan, or they can just be supports that you just provide to this student because it is helpful.
Student Name:
________________________________________
Please check the accommodations/supports that you use in the classroom to support this student.
o Token Economy/Star Chart
o High Frequency of Reinforcement o Break Space
o Visual Supports
o Directions Read Aloud o Extended Time for Tasks
o Simplified and Repeated Directions
o Checks for Understanding (i.e. have student repeat directions back to staff) o Visual Schedule
o Timer
o Teaching of Coping Strategies o Self-Monitoring System
o Noise Canceling Headphones o Alternate/Sensory Seating o Sensory Materials
o Frequent Breaks
o Other:
RELEASE & HOLD HARMLESS AGREEMENT
Initial ____________
Initials ___________
Initials __________
Initials ___________
Initials _________
Initials _________
Virtual Program Waiver*
Initials _________
COVID-19 Acknowledgement Waiver*
Initial ____________
Parent/Guardian Signature Member Signature Date
I give my permission for my child to be transported in the BGCO van/bus for local Oceanside activities.
I give my permssion for BGCO to contact my child using phone calls, zoom, google hangouts or alternate methods for virutal instruction.
I am aware of the contagious nature of COVID-19 and voluntarily chose to allow my child(ren) to participate in programs operated by the Boys &
Girls Clubs of Oceanside (BGCO).
I acknowledge that BGCO employees come into contact with multiple individuals, and might become exposed to COVID-19. I also acknowledge that although BGCO takes precautions to reduce the likelihood of transmission of COVID-19 by its employees, BGCO cannot guarantee that my child(ren) will not become infected with COVID-19.
I knowingly acknowledge that by allowing my child(ren) to participate in BGCO’s programs, I am exposing my child(ren) and myself to the risk of becoming infected with COVID-19, which may result in serious personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by COVID-19 may result from the actions, negligence, and failure to act of myself and others, including, but not limited to, BGCO employees, and other program participants and parents.
I agree to assume all of the foregoing risks, and accept personal responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability or expense, of any kind of nature, that I may suffer arising out of or in connection with my child(ren) or myself becoming exposed to or infected by COVID-19 while my child(ren) is/are participating in any BGCO programs. On my own behalf, and on behalf of my child(ren), I hereby release and hold harmless the BGCO, its employees, agents and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any nature (“Claims”) arising out of or in any way connected with my child(ren) or myself becoming exposed to or infected by COVID-19. I understand that release includes any Claims based on negligence, action or inaction of any of BGCO, its employees, agents, and representatives, and covers bodily injury (including death) due to COVID- 19, whether a COVID-19 infection occurs before, during or after participation in any BGCO program.
I understand that either parent/guardian listed on this application may be contacted regarding the member and their account with BGCO.
I, do hereby give my son/daughter permission to attend and participate in activities sponsored by the Boys & Girls Clubs of Oceanside (BGCO). I hereby release the Boys & Girls Clubs of Oceanside, its employees, associates and contributors from any liability, and injury, loss or damage incurred by my son/daughter while participating. I hereby hold harmless and release the Boys & Girls Clubs of Oceanside from any lawsuits, claims, action, damages, judgments and fees arising out of any personal injury including death or and death of injury which results or increases by any action taken to medically treat my child. I hereby authorize medical emergency treatment for my son/daughter by licensed professional in the event of an accident and release the Boys & Girls Clubs of Oceanside from any liability resulting from this treatment. I give consent to and authorize the use and reproduction of any photographs, likeness and or any other audio-visual material taken of my child for promotional material, fundraising events, and sponsored programs of for any other use for the benefit of the program.
I release the BGCO as After School Educational and Safety Program providers from any liability, any injury loss or liability incurred by my child while participating. I authorize medical emergency treatment for my child by licensed professional in the event of an accident and release the program from any liability resulting from this treatment.
I agree that I have received a copy of the BGCO "Parent Handbook" and agree that I and my child will adhere to all BGCO policies and expectations outlined therein.
I give consent to BGCO to use my child's picture or likeness for publication.