After School Program 2020 Application

We are excited to bring a virtual after school program for the 2020-2021 school year! Music, art, cooking, and other special events will be offered on a monthly basis throughout the school year! Please note that these programs will be given over via zoom so access to internet and a computer or tablet is needed.

Start date: November 2020-May 2021

Time: 3:30pm-5pm

Place: Zoom

Age: Participants must be between 9-17 years old.

*Please contact us if child is outside age group and wishes to join!

Cost: This is a free program

Specific schedule:

Music: 3:30pm-4:30pm the first Tuesday of every month starting November 3, 2020-May 4, 2021

Art: 3:30pm-5pm the second Tuesday of every month starting November 10, 2020- May 11, 2021

Cooking: 3:30pm-5pm the third Thursday of every month starting November 19, 2020- May 20, 2021

Special events: 3:30pm-4:30pm the last Tuesday of every month starting November 24th, 2020-May 25, 2021

If you have any additional questions please contact miriam@epilepsynorcal.org.

Child General Information

First Name

Last Name

Nickname (If applicable)

Birth Date

Age

Child's T-shirt size (unisex size)

Guardian's Name

Cell Phone

Home Phone

Work Phone

Parent/Guardian Email

Guardian's Name

Cell Phone

Home Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State/Province

Postal Code

Is this address different than your Parent/Guardian address?

Preferred Phone Number

Emergency Contact Information

Emergency Contact 1

Phone

Relationship to Applicant

Emergency Contact 2

Phone

Relationship to Applicant

General Health

Applicant's overall health

Does the applicant have any other medical conditions or physical disabilities?

Seizures

When was first diagnosed with epilepsy?

Type of seizure (s), typical seizures look like

How frequent?

Average length of seizure?

Are there any specific seizure triggers?

Warning before the seizure?

How does the applicant react following a seizure?

Is there anything else we should know?

Does your child have any food allergies?

What is your child's favorite hobbies?

What types of art activities does your child/teen enjoy?

Informed Consent and Acknowledgement

I hereby grant to the Epilepsy Foundation of Northern California the absolute and irrevocable right and unrestricted permission to use my or my family’s name, likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, virtual programs, digital images, and the like, taken or made on behalf of the Foundation or its partners. I agree that the Foundation has complete ownership of such material and can use said material for any purpose consistent with the Foundation’s mission. These uses include, but are not limited to, videos, publications, advertisements, news releases, Web sites, and any promotional or educational materials in any medium. I acknowledge that I will not receive any compensation for the use of such images, video, likeness, etc.

I hereby release and discharge the Foundation, and its agents, representatives and assignees from any and all claims and demands arising out of or in connection with the use of my name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of

image, and/or defamation.

I represent that I am over the age of eighteen (18) years and that I have read the foregoing and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns.

This agreement is being made and entered into under the laws of the State of California and shall be governed and interpreted in accordance with the laws of said state. This agreement embodies the entire agreement of the parties (subject and photographer). No modification of this agreement shall be of any effect unless it is made in writing and signed by all of the parties to the agreement.

I have read, understand, and agree to the aboveI do not grant permission

Camper's Name

Parent/ Legal Guardian Name

Parent/ Legal Guardian E-Signature

Date

Contact Information