2024-2025 Enrollment Packet

Welcome to Horton’s Kids! Supporting children in southeast DC is at the heart of our mission. Our holistic approach centers on partnership: connecting with the child, their family, school, and community - to ensure they graduate from high school ready for success in college, career, and life.

As an enrolled family, your child is eligible to participate in a variety of enriching programs and services, including:

Access of Community Centers
After-school Meals
Literacy and Math Programs
STEAM and Enrichment Activities
Homework Help
Summer Programs
HK Store and HK Pay
Mentoring (7^th-12^th grade)
School Advocacy and School Enrollment
College and Career Coaching
Therapy and Counseling
Family Fun Nights
Community Events and Celebrations

Participation in the following youth programs is determined by attendance and behavior, with invitations extended to children who demonstrate consistent attendance and positive behavior:

Field Trips and Special Events
Sleepaway Summer Camp for grades 5^th-12^th
Off-site Enrichment Activities
Holiday Parties and Celebrations

Horton’s Kids families and caregivers also receive access to the following programs and services:

Family Essentials: Grocery Bag, Cleaning Supplies, Personal Hygiene, Diapers, Winter Coats, Thanksgiving Food Basket, Holiday Gifts.

Adult Programs: Career Readiness, Workshops, Parent Advisory Council, Men’s Group, Women’s Group, Adult Socials, Health Consultations, Spades Competitions, and more!

This packet contains the following forms:

1.     Student Information: Details about the parent, child, school, and emergency contacts.
2.     Parent or Guardian Information: Obtain essential details about the parent or guardian.
3.     Health Information: Provide medical details for emergencies at centers or during off-site programs.
4.     Parental Permission: Grant consent for your child's participation in center-based and off-site programs.
5.     Visual & Photo Release: Permit Horton’s Kids to utilize images for promotional and informational purposes.
6.     Student Information Release Form: Enable School Advocacy by facilitating enrollment, obtaining report cards, and meeting with teachers.
7.     DCPS FERPA: Grant DCPS permission to share educational data about your child if marked "yes".

New Families: Please provide the following documents:

1.     Proof of Address (ID, Utility Bill, etc.)
2.     Copy of Child’s IEP, if applicable.

Parent Contact ID

Household ID

Primary Caregiver Contact ID

HORTON’S KIDS
ENROLLMENT FORM – 2023-2024

What neighborhood do you live in?

Household Information

Parent/Caregiver’s First Name

Parent/Caregiver's Last Name

Date of Birth

Relationship to Child

Phone

Email

Full Name 2

Second Parent/Caregiver’s First Name

Second Parent/Caregiver's Last Name

Date of Birth

Relationship to Child

Email

Phone

Home Address

APT #

City

State

Zip Code

Ward

How many children are you enrolling today? (please select a number between 1-8)

Child Information

Child First Name

Child Last Name

Date of Birth (Child)

Gender

SCHOOL Attending 2024-2025:

GRADE 2024-2025:

Please specify any medical, physical, or mental health conditions requiring attention. If none, please write "none."

Please list any food allergies. If none, please write "none."

Please list any regular medications your child takes. If none, please write "none."

Childs Full Name

number of responses

Kid's Contact ID 1

Emergency Contact Information In case of an emergency and we cannot reach the parent or guardian, who can we call?

Emergency Contact Person Name

Phone

Relationship to Child/Children

What Children live in your home that are not getting enrolled in HK?

First Name

Last Name

Date of Birth

What other adults, who are not listed as caregivers, live in your home?

First Name

Last Name

Date of Birth

SURVEY PERMISSION:

Periodically, Horton’s Kids and its associates conduct surveys for enrolled children and families to evaluate our performance. These surveys help us tailor our services to meet community needs and improve our programs and services.

Yes, my child/children can participate in surveysNo, my child/children cannot participate.

Medical Information

Medical Info

Doctors Name

Phone

Dentist Info

Dentist's Name

Phone

Medical Insurance

Insurance Provider

ID #

Medicaid Phone Number

Total Kids

Consent for Use of Visual Image(s) – PHOTO CONSENT

I, (your name)

the parent and/or legal guardian of (child/children name/s)

a minor child who participates in programs and/or activities sponsored by Horton’s Kids (the “Corporation”), hereby give my consent to the taking, use, publication and reproduction of the visual image of said minor child (whether obtained by photographic, digital or other means) by the Corporation, its agents, consultants or contractors, in connection with any advertising, promotion or other activity undertaken by the Corporation in furtherance of its corporate purposes.

I understand that, if the visual image of said minor child is posted on the Corporation’s website and/or on social media channels, the Corporation cannot prevent the unauthorized reproduction and use of said visual image.

On behalf of said minor child, I hereby waive any and all claims that I or the minor child might otherwise have for invasions of privacy, as well as any and all claims for payment or royalty in connection with the showing, publication or display of the visual image of said minor child, and agree that my consent confers no rights of ownership in the visual image whatsoever.

I agree to indemnify and hold harmless the Corporation, its employees, agents, consultants and contractors, from and against any claim, cost, damage, or expense arising from a breach by me of the foregoing consent.

Yes, I give media consent.No, I do not give media consent.

PARTICIPANT PERMISSION FORM

The Program: Horton's Kids, Inc. (“Horton's Kids”) is a non-profit corporation created to provide academic, enrichment, and health and basic needs services to children in Washington D.C.

The main activities sponsored by Horton's Kids include, but are not limited to, the following:

Weekly tutoring
Homework help (after-school, on-site)
Enrichment clubs, activities, and field trips (with partner organizations)
Summer programs
Sleepaway camp (with partner organizations)
Youth Development Supports
Mentoring
Case Management/Success Coaching
Mental and Physical Health Supports:
Referrals for individual, group, or family therapy
Assistance with school/camp physicals, vision screenings, speech therapy
School Advocacy & Enrollment Support:
Collaboration with teachers
IEP process assistance

I am aware that participation by my child in the program described above (the “Program”) involves risk of injury. I understand that the risks will vary depending upon the activities planned. I understand that certain activities (such as those involving water, running or other athletic activities) are inherently dangerous and involve many risks of injury, including, but not limited to, serious bodily injury and death. I have identified below any activities in which my child does not have permission to participate.

I have provided to Horton's Kids all medical information about my child that Horton's Kids would need to know in the event of a medical emergency, including all of my child's known allergies and other medical conditions. I have provided all additional information about my child that I consider important to my child’s participation in the Program. I have instructed my child to adhere to all instructions given by Horton's Kids, its officers, directors, employees, volunteers, and agents and I assume responsibility for my child's compliance with such rules, regulations, and instructions.

In consideration for allowing my child to participate in the Program, I hereby assume all the risks associated with the Program and agree to hold Horton’s Kids, its officers, directors, employees, volunteers, and agents harmless and indemnify them from any and all liability, causes of action, suits, controversies, obligations, claims, debts, or demands of any nature whatsoever which may arise in connection with my child’s participation in the Program, including, without limitation, those which may arise through the negligence of the officers, directors, employees, volunteers, and agents of Horton’s Kids or of any other participant in the Program.

I, as the parent or legal guardian, give my permission to Horton’s Kids for my child to participate in the Program, except for those activities I have excluded below. I give my permission to Horton's Kids, its officers, directors, employees, volunteers, and agents to transport my child by chartered vehicle or by private automobile to and from activities planned as a part of the Program, except as excluded below.

Name of Child/Children

Name of Parent/Guardian:

Please specify any restrictions or pertinent information regarding your child's participation in Horton’s Kids programs, including activities, transportation, medical considerations, or any other relevant details:

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Regarding:

Childs Full Name

Date of Birth

I, the Undersigned:

Printed Name of Parent/Legal Guardian

I I authorize HORTON’S KIDS to release and receive information.I do not authorize HORTON'S KIDS to release and receive information.

School Name

Confidential record information for the purpose of:

School enrollment, IEP meetings and advocacy, school records/academic progress, social, emotional, and behavioral health.

As the person signing this authorization, I understand that I am giving my permission to HORTON’S KIDS for disclosure and/or receipt of confidential educational records. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my educational records and is not effective as to the educational records already disclosed under this authorization. I understand that information disclosed under this authorization might be redisclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such information was protected by law while solely in the possession of HORTON’S KIDS.

This consent is for one year from the date of origination.

Office of the Chief Academic Officer

1200 First Street, NE | Washington, DC 20002 | T 202.442.5885 | F 202.442.5026 | www.k12.dc.us

Office of Out-of-School Time

1200 First Street, NE 8th Floor

Washington, DC 20002

202-442-5002

OutofSchoolTime@dc.gov

In an effort to serve your child better in the afterschool program at his/her school, and to ensure that the program meets your child’s academic needs, DCPS works with organizations that specialize in providing afterschool programs (Afterschool Providers). In order to more effectively tailor the afterschool program to your child’s needs, further cultivate his/her strengths, and identify and develop areas where he/she is in need of

improvement, DCPS would like to share certain student records related to your child with his/her school’s Afterschool Provider(s). Under the Family Educational Rights and Privacy Act (FERPA), DCPS must first obtain your consent before sharing education records with the Afterschool Provider(s) at your child’s school.

Please indicate below whether you consent to give the Afterschool Provider(s) at your child’s school access to your child’s demographic data, test scores, quarterly grades and, if applicable, Individualized Education Program materials. If you choose to consent to DCPS’ sharing of this information about your child with the Afterschool Provider(s), you may request that DCPS provide you with a copy of the records disclosed. All staff members of the Afterschool Provider(s) with a right to access your child’s education records have signed confidentiality agreements regarding the privacy of your child’s education records.

Child/Children's Names

Select only one of the following

It is important for us to get School Records for your child. Please let us know that we have your consent.

I consent to DCPS’ sharing of my child’s/children's demographic data, test results, quarterly grades and, if applicable, Individualized Education Program with the Afterschool Provider(s) at my child’s school for purposes of academic enrichment.I do not consent to DCPS’ sharing of my child’s/children's demographic data, test results, quarterly grades and, if applicable, Individualized Education Program with the Afterschool Provider(s) at my child’s school.

2024-2025 Enrollment Packet

HORTON’S KIDSENROLLMENT FORM – 2023-2024

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Select only one of the following

HORTON’S KIDS
ENROLLMENT FORM – 2023-2024