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Intro

Big Thought
THRIVING MINDS
A Program of Big Thought


2019-2020 After School Enrollment Packet
Thank you for your interest in the Thriving Minds After School. On the following pages you will find forms that must be completed by a parent or guardian in order for your child to be enrolled in the program.

Please note: your child will not be allowed to attend the program until all required documents have been received by the Thriving Minds staff. Please complete all pages in this form as soon as possible as enrollment is offered on a first-come, first-served basis.

Also, a separate application must be filled out for EACH child to be enrolled.

If you have questions about the program, please contact Big Thought at 214-520-0023.

List of Items Needed to Complete Form
To complete this application you will need to have the following information ready:
  1. Your student’s school ID number
  2. Health insurance information for the child (Insurance Company name and phone number)
  3. Emergency contact information (Name, phone, and email address)
  4. Approved persons who can pick up the student (Name, phone, and photo ID information)

Page 1

Big Thought
THRIVING MINDS
A Program of Big Thought

Enrollment Application

Please complete all pages.  When you have finished you will submit your e-signature and then receive an email asking you to verify your email address.  Please click the link in the email to confirm it and then you have completed the application process.

Student Information







* Student ID number is available at the school's main office.

MM/DD/YYYY

Page 2

Emergency Information
The following information is required in case of emergency. The Health and Medical form will be transported with your child to the nearest clinic/hospital to assist the paramedics and hospital staff. This form is also required to be with students during all field trips, if enrolled in a Thriving Minds program.








Important Health Information
I, the undersigned, do hereby authorize employees of Big Thought to contact directly the person and healthcare provider named on this form, and do authorize the named physicians, clinics and/or hospitals to render such treatment as may be deemed necessary for the transportation and healthcare for said child. In the event the physicians, other persons named on this form or parents cannot be contacted, Big Thought staff and the school employees are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the aforesaid child. (Section 35.01, Texas Family Code). I will not hold the school district or Big Thought financially responsible for the emergency care and/or transportation for said child. I request that the physicians, dentists and staff of the medical facility perform any diagnostic procedures, treatment procedures, operative procedures, x-ray treatments and anesthetics as may be necessary in the diagnosis and treatment of my child. I authorize the medical facility to dispose of any specimen or tissue taken from the named person. I certify I am a parent with the legal control of the child, the child’s legal guardian or have other court ordered control of the child. I understand that I must notify the Thriving Minds program in writing to change any information on this form or to revoke any consent given herein. I understand it is a penal code offense to falsify information for enrollment. I testify all information on this document to be true and correct.

Page 3

AUTHORIZED ADULTS
The Parent/Guardians listed below, as well as the three Contacts listed on the next page, will be allowed to pick up a student, if marked for pick up. The information listed below will replace all existing information on pick-up contacts at the time this form is received by Thriving Minds staff. No contacts are entered into the system without PHOTO ID. Older siblings may pick up provided there is a signed permission letter and photo ID of the sibling on file with the Thriving Minds staff on campus.  Copies of these Photo ID's must be provided to Thriving Minds Staff at the Program location.

Please Note: If child cannot be released to non-custodial parent, we must have legal documentation on file.
CUSTODIAL PARENT OR GUARDIAN (Required)










Ex: State of Texas, US Gov.
SECOND PARENT OR GUARDIAN (Optional)










Ex: State of Texas, US Gov.

Page 4

AUTHORIZED ADULTS, Continued
Please list up to three (3) additional contacts who may pick up your child (at least one (1) is required).  You must enter the type of Photo ID they have and what the ID Number of the Photo ID is.
Contact 1 (Required)
(Driver's License, Passport)



Contact 2
(Driver's License, Passport)



Contact 3
(Driver's License, Passport)



After School Parent/Guardian Letter of Understanding


1. I acknowledge I will receive a copy of the Thriving Minds Parent/Guardian Handbook upon completing this form, and that I will review it.

2. Each student is permitted ONE written warning about unacceptable behavior.  Should unacceptable behavior occur again, the student will be dismissed from the program.

3. Late pick-up policy: Children must be picked up by the stated Program End Time. Each child is extended one no-charge late pick-up before additional fees are assessed. After the first late pick-up occurrence, Parent/Guardian will be charged a fee of $1.00 per minute for every minute late late. Children who are picked up late more than five times may be dismissed from the program.

4. Fighting is not allowed in the Program. Depending on circumstances, children may be dismissed for fighting.

5. Children must come directly to the Program after the regular school day is dismissed. Parent/Guardian must inform Thriving Minds staff in advance, should a child not be attending the Program that day.

6. If a child leaves the Program area(s) without permission from a Thriving Minds staff member, the child will be dismissed from the Program. A child must always ask permission to leave a room or a playground, etc., unless an obvious emergency is taking place.

7. All children are encouraged to stay to the end of the Program day to receive full benefits of the Program activities.

8. As stated, only Authorized Adults are permitted to pick-up children.  

9. I understand that Big Thought conducts an annual evaluation of Thriving Minds, and as part of that evaluation Big Thought may administer surveys to my child, administer academic and/or social and emotional learning assessments to my child and may access student records in compliance with FERPA regulations. I understand that Big Thought will:
• Keep all individual information confidential to the extent allowed by law.
• Never report on a child by name or identifying information and will only share information in the aggregate (meaning overall results), so that there will be no personally identifying information released about a child from Big Thought. 
• I also understand that my consent is voluntary. My decision whether or not to allow my child to participate in the program assessment will not prejudice my present or future relations with Big Thought or my child’s School teacher or other School official. If I permit my child to participate, I am free to discontinue participation at any time without prejudice. I understand that if I withdraw my student from the project, my student’s information will be removed from the project results.  I understand that I can request copies of the evaluation tools by contacting Big Thought at Shannon.epner@bigthought.org

10. As part my child’s experience in Thriving Minds, my child will participate in Dallas City of Learning (DCoL), an 
education initiative and online platform designed to help students discover new interests, develop skills and earn recognition for their learning achievements. DCoL is a partnership with the Dallas Mayor’s Office and Dallas ISD, and is managed by Big Thought. A protion of data that has been provided, including the child's name, birth date, and Parent/Guardian email or phone, will be shared with DCoL to enable your child’s participation.
permission for my child to participate in Program Assessment as outlined in Item #9

Informed Consent and Publicity Release


I, the undersigned, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, hereby (1) authorize Big Thought, A Learning Partnership (“Big Thought”) and its Board of Directors, officers, employees, agents, representatives and associates of their respective staff and anyone authorized by them (collectively, “Big Thought”) the unrestricted and irrevocable right to photograph, video and record me in connection with Big Thought program(s) in which I am participating, have participated or will participate (“Programs”) and (2) grant to Big Thought the unrestricted and irrevocable right to use, publish, reproduce, edit, adapt, modify, exhibit, project, distribute, and display such photographs, videos and recordings, and my name, image and likeness, voice and statements and story (collectively, the
“Content”), in any form of media now known or later developed (including without limitation print, digital, electronic, visual, broadcast, Internet and social media, or otherwise), individually and in conjunction with other content, throughout the world and beyond into perpetuity.

Big Thought will own all of the Content and any other results generated by myself as part of my participation in Big Thought Programs, and any physical material to which such Content is affixed, including but not limited to any videotapes, photographs, print materials, canvas, poster boards or digital media. I release and waive any claims whatsoever in connection with the use of the Content as expressly authorized above, including, without limitation, any claim of rights of privacy, publicity, copyright infringement, defamation, so-called “moral rights,” or credit. I also release and waive any right I may have to inspect or approve the Content or any use thereof as expressly authorized above. Additionally, I waive the right to any royalties or other compensation relating to the use of the Content.

I hereby hold harmless and release and forever discharge Big Thought and all persons, corporations or legal entities acting with its permission or upon its authority, from any and all claims, demands, and causes of action which I, my heirs, representatives, executors, administrator’s, or any other person acting on my behalf or on the behalf of my estate have or may have by reason of this agreement or the use of the Content as expressly authorized hereunder.

I acknowledge that Big Thought is conducting its activities in express reliance upon the foregoing, and I represent and warrant that I am not a party to any other existing agreement which would prevent me from entering into this agreement or granting the above rights to Big Thought or which would cause the terms of this agreement not to have full force and effect.
FOR MINOR CHILD OR WARD: I, the signer of this document, represent that I am the parent and/or guardian of the minor named below. I represent that I have the legal authority to, and hereby do, execute the preceding consent and release on behalf of such minor.
permission for Big Thought to use my child's photo or likeness as described above.

TUITION AGREEMENT


You are enrolling your child in a fee-based Thriving Minds After School program for the 2019-20 school year and agree to pay the tuition fees as set forth in this Agreement. The Tuition Agreement must be signed and returned for enrollment to be completed. By signing this agreement you acknowledge that this program is fee-based and that in fairness to all Thriving Minds participants, payment is required in a timely manner.
Fee Structure
Hernandez
Hernandez Fee Structure
Highland Meadows
Highland Meadows
Lakewood
Lakewood
Payment Options
Thriving Minds After School tuition will be remitted on a pre-payment basis and is due the Friday prior to each program week. Tuition will not be charged for non-program days such as student holidays.
Payment Process
Payment is due the Friday prior to each program week. Payment shall be delivered to the Thriving Minds staff at your program location. Payment can be made by CHECK or MONEY ORDER and payable to: Big Thought.

Alternatively, Payments can be made by CREDIT or DEBIT CARD through the Big Thought parent portal, Jackrabbit.  You will be given login information after the first week of programming.
Registration
A registration fee of $5 is assessed for each application (one application required for each student), and payment is due the first day of the Program.
Registration
No registration fee is assessed, but payment for the first week of programming is due the first day of the Program.
Lakewood Elementary Registration
A $20 registration fee is assessed, and payment for the first week of programming is due 8/19/2019.
Withdrawal and Refund Policy
  • Tuition fees are calculated on a weekly basis and not prorated for daily attendance.
  • Tuition fees are not prorated for late arrivals or early pick-up.
  • A fee of $1 per minute will be charged for late pick-up from the Program.
  • If Program Day is cancelled by Big Thought or cancelled due to inclement weather, a full refund for that day will be issued in the form of a credit to your account.
  • If a child is expected to be absent for a Program Week(s), a Parent or Guardian must notify Thriving Minds staff of the expected absence no less than one week (five business days) prior to the absent Program Week(s) to qualify for a refund for the absent Program Week(s).  Should no notification of the expected absence be made, or be made less than one week (five business days) prior to the absent Program Week(s), no refund will be made and child will be charged for the absent time.
  • If a child must withdraw from the Program, a Notice of Withdrawal form must be completed by a Parent or Guardian and submitted to Thriving Minds staff no less than one week (five business days) prior to the date of withdrawal. A refund of 50% of any unused fees paid less a $20 processing fee will be made. Should the Notice of Withdrawal form not be submitted in a timely manner, per above, no refund will be made and a $20 processing fee will be assessed.
  • No refund will be made if a child is dismissed from the Program for violation of a Handbook policy.  A $20 processing fee will be assessed.
Late Payment Policy
A $5.00 late fee will be assessed for late payments. Children will be permitted to continue to attend up to 5 days after payment was due. After 5 days, children may not attend until payment is made.
I, the undersigned, understand and agree to the terms outlined in this Tuition Agreement.

CORE

Parent Permission to Participate in an Evaluation Study
SMU
Dear parent,

Your child’s afterschool program has chosen to participate in an ongoing evaluation study, coordinated by Dallas Afterschool in collaboration with SMU’s Center on Research and Evaluation (CORE). This study will measure academic, social-emotional, and attendance outcomes for students enrolled in Dallas area afterschool programs. We are conducting this study in order to understand how the quality of afterschool programs impacts student outcomes, as well as to identify what Dallas Afterschool can do to help programs use best practices. The purpose of this project is to provide Dallas Afterschool with information that will benefit your child, his/her afterschool program, and the Dallas afterschool community.

Your child will participate in their afterschool or summer program as usual. Nothing about the program will change. If you choose to have your child participate in this study, a few additional things may happen:
•Your child will be asked to complete a brief survey twice during the school year; this will take about 30 minutes total. This is voluntary: even if you say its ok, your child can say no.
•Staff at your child’s program will complete the DESSA-mini social-emotional assessment and will keep attendance records about your child. This will not require any time from your child.
•CORE, on behalf of DAS, will request data about your child’s academic performance from the school or district they attend. This will not require any time from your child.

What will happen to my child’s data?
CORE and DAS are collaborating to work on different parts of this evaluation.
•DAS will share the data collected through your child’s program with CORE.
•At times, the program that your child attends may also share information directly with CORE.
•DAS may share information about your child with the program your child attends.
•CORE staff will analyze your child’s data, and DAS staff may analyze the same data.
•CORE and/or DAS may use your child’s or child’s program data for different purposes, including to improve afterschool and summer programs, and to conduct additional research in the future. This may include accessing additional information about other program(s) or activities your child participates in.

CORE and DAS will maintain your child’s name and, if available, their Dallas ISD or other school identification number, so that we can get information from Dallas ISD about your child’s academic performance. SMU and CORE are fully committed to keeping all collected information private. All information provided to CORE will be kept in locked file cabinets at CORE offices and on secure computer servers located at SMU. SMU secures its computer system with strict security measures. Every effort will be made to restrict your child’s data to people who need to review it for the purposes of this project, and this includes both CORE and DAS staff, and may include staff at the program your child attends.

What should I know about giving CORE permission to request my child’s school data?
You can choose not to grant CORE permission to request your child’s data and/or assess your child. You may also grant CORE permission now, and then later change your mind. Whether you want to participate or not, nothing about your relationship with Dallas Afterschool, your afterschool or summer program, with SMU, or with your child’s school will change.

Who can I talk to if I have questions?
If you have questions, concerns, or would like more information, you may contact Annie Wright at CORE, at
(214) 768-7717 or core@smu.edu, or Lauren Ammons at Dallas Afterschool (214)-306-8400 x114. This
project has been approved by the Institutional Review Board (IRB) at SMU. You may also contact the SMU
IRB chair Austin Baldwin at (214) 768-2033 or researchcompliance@smu.edu if you have questions about
your or your child’s rights as a participant, or want to speak to someone else other than the project staff.

Are there any risks involved?
There is always potential risk for a privacy breach with electronic data storage. SMU will have all appropriate protocols, such as locked physical storage and commercially appropriate security measures on electronic servers.

My initials indicate that I have read the information provided and have decided to give permission for the following:
• DAS to collect data about my child, including their attendance, their social and emotional skills, and their engagement in school
• CORE to request data from DISD about my child’s academic performance.
• DAS and CORE to share the information they collect with each other in order to conduct the evaluation.
• DAS to share results with the program(s) my child attends.
• Data to be used in these ways for as long as my child is enrolled in a DAS program.
Permission
My initials below indicate that I have read the information provided and have decided to give permission for the following:
• DAS to collect data about my child, including their attendance, their social and emotional skills, and their engagement in school
• CORE to request data from DISD about my child’s academic performance.
• DAS and CORE to share the information they collect with each other in order to conduct the evaluation.
• DAS to share results with the program(s) my child attends.
• Data to be used in these ways for as long as my child is enrolled in a DAS program.

e-Signature

After School Behavioral Contract
Your student will receive this during the first two weeks of programming.  By initialing below you acknowledge you have reviewed this document:

As a participant in the Thriving Minds After School program, I understand that I must:
  1. Follow all rules of the program.
  2. Follow rules I have during the school day.
  3. Treat all adult leaders with respect.
  4. Treat all students with respect.
  5. Report directly to the program each day.
  6. Ask for permission to leave any designated area.
  7. Fully participate in all activities offered to me.
  8. Encourage my parent/guardian to attend events.
  9. Have fun!!!!
After School Enrollment Application
The Thriving Minds program is not licensed by the State of Texas.

Big Thought operates in accordance with the US Department of Agriculture and Texas Health and Human Services Commission policy, which prohibits discrimination on the basis of race, color, national origin, sex, sexual orientation, age or disability.

I, the undersigned, do hereby authorize Big Thought permission, for the purpose of program evaluation, as outlined in parent handbook, to administer surveys to my child, administer academic and/or social and emotional learning assessments to my child and access student records in compliance with FERPA regulations.
This form uses e-Signature to accept your approval of, and agreement to, the forms described above and in detail on the preceding pages, in relation to the student named below.  Please click "e-Signature" to go to the final page and sign the document.

PLEASE NOTE: After you sign the document, you will be sent a VERIFICATION email.  You MUST click the link in that email to complete the e-Signature process!