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Heart House
Summer Registration Form
June 8th - July 30, 2020

Student Information

Demographic Information

School Information

Medical / Dietary Information

Emergency Contacts
Primary Contact

Secondary Contact (In Case of Emergency)

Summer Registration Form
June 8th - July 30, 2020

Authorized Pick Ups

Heart House needs a list of all the people that are authorized to pick up your student from Heart House. This will include you, any siblings, family members or friends. We need this in order to ensure your child’s safety during release time at Heart House. If a person comes to pick up your student from Heart House that is not included on this list, your student will not be released and the parent will be contacted for permission. 

Please list below ALL people authorized to pick up your student from Heart House (include yourself).
Authorized Individual (add as many individuals as necessary)

By filling out the portion below, you are authorizing Heart House to release your student to the people listed above.

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Summer Registration Form
June 8th - July 30, 2020

How Will Your Student Get Home?

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Summer Registration Form
June 8th - July 30, 2020

This document limits your legal rights; please read it carefully before you sign the following pages.

This Agreement covers the use of all Heart House locations by the residents and/or neighbors of Heart House, and their participation in certain activities and events. By signing this Agreement, residents and neighbors agree that they and their children will follow the guidelines herein set forth, agree to certain consequences of any failure to follow the guidelines, and WAIVE CERTAIN LEGAL RIGHTS with regard to use of Heart House facilities or participation in certain activities and events.

1. Heart House is a non-profit that has 501c status and does not have to be regulated by any state agency. It is an Afterschool and Summer program. Attendance records are important for the safety and development of all students. Heart House’s program concludes at 6:00 pm during normal after school operations and 4:00 pm during normal summer operations. It is the responsibility of the parent to meet his/her child at Heart House, should you wish to walk your child home, or have someone else meet your child.

2. Heart House is NOT responsible for any child after he/she has left the Afterschool or Summer Program. Should a child return to Heart House, after having left for the day, to advise the leaders that he/she is either locked out and cannot get into his/her home or the child has not been picked up at the designated time, Heart House staff will first attempt to call the parent, legal guardian, or emergency contact person. If this first attempt is unsuccessful and there has been a fifteen (15) minute waiting period past the stated closing time, for the safety of your child, Heart House has the right to call the police. It is the responsibility of the parent or guardian to make arrangements for the child after h/she leaves the Afterschool or Summer Program.

3. The rules and restrictions regarding use of the computers at all Heart House sites, whether posted or given verbally, must be followed at all times.

4. Any damage to any furnishings or equipment by an adult or by his or her minor child, will be the financial responsibility of said adult. By signing this agreement, you agree to pay for the cost of the repair or replacement of any equipment damaged by you or your minor child.

5. Failure to follow these and other guidelines given to parent, guardian, or his/her child, may result in dismissal from the Afterschool or Summer Program and/or loss of privileges including, but not limited to, using the computers or other resources of the Afterschool or Summer Program.

Please read and respect the following Heart House policies:

1. All children attending the Afterschool and Summer Program must have a current, signed authorization packet on file before participating in Heart House programs.
One registration form covers a child for an entire calendar year. Parents/Guardians will need to update their contact

2. Children are expected to follow the Heart House Code of Conduct at all times. Adults in charge have the authority to determine if a child is or is not abiding by the code of conduct. Due to disobedience, your child could receive discipline action, including but not limited to suspension from Heart House. If for any reason, this occurs, the parent/guardian will be informed that same day with a suspension form from Heart House.

3. Attending Heart House is important for your son/daughter’s growth, development, and for him/her to receive certain incentives tied to attendance. Students must attend Heart House each day of Afterschool and Summer Programs. If they are unable to attend, the parent/guardian should notify their son/daughter’s leader the day before, the day of, or the day after. Attendance is recorded daily.

4. (Regular School Year) One Hour Homework Rule: Every child receives at least one hour of homework help. Every child should bring his/her homework with them to Heart House. Additionally, children participate in engaging activities to build their academic skills as well as receive a hot meal and opportunities to play and connect.

5. (Regular School Year and Summer) Children must attend daily if they are enrolled. In order to be fair to those on our waiting list, your son/daughter will be removed from enrollment after we contacted the parent/guardian three (3) or more times, and/or if Heart House has not received notification to excuse the absence. As a courtesy, your son/daughter will remain on the roster up to 5 days.

6. For the safety of your son/daughter, Heart House Staff and other children enrolled in the program, children who are sick should stay home. If your son/daughter does not attend school because of illness, they should NOT attend Heart House. They should not attend Heart House until they have returned to school. Contact your son/daughter’s leader to inform of the absence.

7. Heart House is often fortunate to receive donations of food from outside sources. If food is available, snacks and/or meals will be given to Heart House attendees and families of attendees.

8. Heart House utilizes many volunteers to run its activities and programs. It is a part of Heart House’s Code of Conduct for children to show courtesy and respect to all adults associated with Heart House.

9. Staff and volunteers go through criminal background checks through the VeriFYI System.


By signing below you are authorizing your child to participate in the following activities and events:


For the safety of your son/daughter, Heart House Staff and other children enrolled in the program, Heart House does NOT distribute nor dispense any medication to students. If your son/daughter takes medication, please ensure appropriate precautions are taken and that you list them on the front of this registration form. In case of an emergency, Heart House will call 9-1-1.

I am the parent or guardian of the child named below. In the event of accident or illness, I hereby authorize the staff of Heart House to summon emergency medical care for my child. Any costs associated with such care are acknowledged to be the sole responsibility of the undersigned. Please contact the individuals listed above in the event of an emergency.
(Please initial)

I am the parent or guardian of the child named below. I hereby authorize the staff or volunteers of Heart House to transport or accompany my son/daughter off-site of Heart House to participate in field trips. Summer and Afterschool field trips include; museums, roller/ice skating rinks, theme parks, water parks, swimming facilities, workshops, colleges/universities, and corporations, among other opportunities. Additional notification will be provided to the parent and or guardian prior to the planned event. 
(Please initial)

I am the parent or guardian of the child named below. I understand that among the educational resources available at Heart House are computers and access to the Internet, and that the Internet gives access to sites that may contain material that is objectionable because of its content. I acknowledge that the staff and volunteers at Heart House will enforce the rule that accessing inappropriate material will result in the loss of computer privileges. However, Heart House cannot guarantee that such material will not be able to be accessed. With knowledge of this fact, I give my son/daughter permission to access the Internet at Heart House. 
(Please initial)

I hereby authorize that artwork, photographs, or writings of my child may be taken or used in connection with his or her participation in learning center programs and activities, and give permission for such artwork, photographs, and writings to be published and or sold in fundraising activities. This may include photos or videos used in printed materials, online newsletters or websites. 
(Please initial)

I hereby authorize the photocopying of all school report cards, and / or test results for inclusion in your child’s Heart House file. I give Heart House Staff permission to receive information regarding grades, standardized test scores, and behavior reports from teachers or school personnel. This information will be kept strictly confidential. The information will be used for purposes of evaluating academic areas in need of improvement and measuring overall performance of your son/daughter through programs offered at Heart House.  
(Please initial)

I hereby authorize the participation of my student in mindfulness practices including, but not limited to, breathing, reflections, whole group and small group soft skill lessons. These are implemented for the increased social-emotional skills of each student, to learn to deal with adversity and use effective problem-solving.
(Please initial)

I hereby authorize the participation of my student in testing administered by Heart House staff. This includes, but is not limited to academic testing, social-emotional testing using DESSA-mini and SDQ, and other formative assessments throughout the school year and summer.
(Please initial)

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Summer Registration Form
June 8th - July 30, 2020

We are a Heart House Family.
1. (is) Polite and respectful.
2. (is) Kind.
3. Speaks up for others being mistreated.
4. Takes responsibility for their actions.
5. Encourages and helps one another for good.
6. Leaves no one out.

Heart House students are expected to conduct themselves accordingly. Violating the code will result in consequences, to include, but not limited to removal from program.

Heart House Principles:
1. Heart House students are expected to treat one another and others as family.
2. Heart House students are in a safe environment.
3. Heart House students are expected to care for all Heart House property.
4. Heart House students have an equal opportunity to learn and participate.
5. Heart House students develop holistically- head, heart, hands.

As part of the consideration for, and as a condition to, Heart House agreeing to allow my son/daughter to participate in the Afterschool or Summer Program, I hereby agree to RELEASE AND HOLD HARMLESS Pallas Realty Advisors, Inc., Stratford Hill Apartments, SMI Realty, The Wildflower Apartments, Heart House Dallas, and their principals, partners, officers, directors, managers, agents, employees and representatives, successors, and assigns. I RELEASE AND HOLD HARMLESS from any and all claims, costs, damages, causes of action, and liability of any kind, from any cause whatsoever, arising from the use of the facilities, equipment, or playground, of the Heart House Afterschool and/or Summer Program or participation in the events or activities of the Heart House Afterschool or Summer Program by the undersigned or by any of the minor children of the undersigned. Your signature on this document will be valid for as long as your son/daughter participates in any Heart House program from this date forward.