Heart House Application SY 22-23

Introduction

Welcome! At Heart House, we believe every child deserves the opportunity to learn and grow in a safe environment where self-expression, creativity, and diversity are celebrated. For more than twenty years, Heart House has been that safe space for numerous children in the Vickery Meadow neighborhood. Our afterschool program provides your student with academic help and social-emotional support.

Heart House's School Year 2022 - 2023 program will be held at Jill Stone Elementary on Mondays - Thursdays from 3:00 PM - 6:00 PM.

Before submitting your child's application, please ensure that all information is current and accurate.

Haga clic aquí para acceder a la aplicación en español.

Student Information

First Name:

Middle Name:

Last Name:

Date of Birth:

Age:

Gender:

Please specify:

Ethnicity:

Please specify:

Name of School:

Grade:

Medical/Dietary Information

Does your child have any food restrictions?

Check one or more:

Please specify:

Does your child have any known allergies?

Please specify:

Does your child have any health concerns?

Please specify:

Is your child currently taking any medications?

Please specify:

Does your child have a diagnosed learning disability?

Check one or more:

Please specify

Does your child struggle in any areas in school?

Check one or more:

Please specify:

Do you have any additional concerns about your student?

Please explain:

Dismissal Method

How will your student get home after Heart House?

Please choose one:

Please list all Heart House students who need to walk with your child:

Please choose one:

YOUR STUDENT WILL ONLY BE DISMISSED ACCORDING TO THE METHOD YOU CHOSE ABOVE.

Family Information

Home Address:

Apt #:

Zip Code:

Country of Origin:

Home Language:

How many years has your family lived in Texas?

Household Yearly Income:

First Emergency Contact: Primary Parent/Legal Guardian (to be contacted in case of emergency AND for pick up)

THIS INDIVIDUAL WILL BE CONTACTED IN THE EVENT OF AN EMERGENCY AND IS AUTHORIZED TO PICK UP YOUR STUDENT FROM HEART HOUSE PROGRAM.

First Name:

Last Name:

Phone Number:

Employer:

Relationship to Student:

Please specify:

Second Emergency Contact: Secondary Parent/Legal Guardian (to be contacted in case of emergency AND for pick up)

THIS INDIVIDUAL WILL BE CONTACTED IN THE EVENT OF AN EMERGENCY AND IS AUTHORIZED TO PICK UP YOUR STUDENT FROM HEART HOUSE PROGRAM.

First Name:

Last Name:

Phone Number:

Employer:

Relationship to Student:

Please specify:

Authorized Individual

PLEASE LIST ANY OTHER INDIVIDUALS WHO HAVE PERMISSION TO PICK UP YOUR STUDENT FROM HEART HOUSE PROGRAM.

First Name:

Last Name:

Phone Number:

Relationship to Student:

Please specify:

Heart House Permissions and Authorizations

Permission for Counseling

PLEASE CHECK ONE AND INITIAL THE FOLLOWING PERMISSION.

I give permission for my child to work with the Heart House partner for counseling. I have read and understood the documents given to me which discuss the nature of counseling, confidentiality, and HIPAA. I give permission for my child to complete surveys that will be used in research by Heart House. My child's identifying information will be removed prior to use of responses for research purposes.

Check one:

Please initial:

Waiver, Hold Harmless and Release

PLEASE INITIAL THE FOLLOWING WAIVER.

As part of the consideration for, and as a condition to, Heart House agreeing
to allow my child to participate in the Afterschool or Summer Program, I hereby agree to RELEASE AND HOLD HARMLESS SMI Realty, The Wildflower Apartments, Heart House Dallas, and their principals, partners, officers, directors, 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 a lid for as long as your child participates in any Heart House program from this date forward.

Please initial:

Authorizations

PLEASE READ AND INITIAL THE FOLLOWING AUTHORIZATIONS.

1. MEDICAL TREATMENT AUTHORIZATIONS
For the safety of your student, Heart House Staff and other children enrolled in the program, Heart House does NOT distribute nor dispense any medication to students. If your child 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. 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 aforementioned in the event of an emergency.

Please initial:

2. FIELD TRIP AUTHORIZATIONS
I am the parent or guardian of the child named. I hereby authorize the staff or volunteers of Heart House to transport or accompany my student off-site of Heart House to participate in field trips. Summer and Afterschool field trips include; museums, swimming facilities, outdoor facilities, 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:

3. ARTWORK, PHOTOS, AND WRITINGS RELEASE
I am the parent or guardian of the child named. I hereby authorize that artwork, photographs, or writings of my student 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:

Parent Handbook

PLEASE CLICK ON THE FOLLOWING LINK TO READ THE HEART HOUSE PARENT HANDBOOK AND INITIAL THE FOLLOWING STATEMENT.

I have received a copy of the Heart House Parent Handbook. I read and agree with the handbook.

Please initial:

Thank you for filling out an application for your child.

Heart House staff will be in contact with you to confirm that we received your application and that your child may attend program.

PLEASE CLICK "SUBMIT" TO FINALIZE YOUR RESPONSE.