Third Baptist Freedom School Scholar Enrollment Form

Today's Date:

Child's Last Name:

Child's First Name:

Child's Middle Name:

Birth Date:

Age

Home Street Address:

City:

State:

Zip Code:

Has your child received his/her COVID vaccinations and boosters?

The Third Baptist Freedom School requires both the primary COVID-19 vaccination and the recommended booster shots. Please upload your scholar's vaccination card here. If you have an electronic version, you may screenshot the verification and upload below (make sure the scholar's name and vaccination date is included on the screenshot).

Please upload a clear frontal photography of your scholar here. We'd like to put a face to the name.

T-Shirt size

Gender Identity:

Gender Identity Other:

Preferred Pronoun:

Preferred Pronoun other:

Child's Race/Ethnicity (Check all that apply):

Child's Race/Ethnicity other:

Please list any languages your child speaks at home.

Is your child an English Language Learner? (English is not their first language)

Child's grade just completed:

What is your child's Reading Proficiency level?

Has your child ever qualified for an individual Educational Plan (IEP) or 504 plan?

Type of school that your child attended past school year:

Other

Child's School Name, City and State:

Does your child receive or qualify for free/reduced price lunch at school during the academic school year?

Has your child ever attended a CDF Freedom Schools Summer or After-school program in previous years?

If yes, how many years has your child participated in the CDF Freedom Schools program?

What are some of your child's interest such as hobbies, extracurricular activities, or passions? (Ex. my child enjoys cooking, singing, and robotics, etc.)

What additional support can we provide for your scholar to uplift their self-confidence?

Does your child have any allergies or health conditions of which we should be made aware? if yes, please list them?

Is there anything else you'd like to share about your child?

Adult's Last Name completing this form:

First Name:

Middle Name:

Relation to Child(ren)

Is this individual a legal guardian?

Gender Identity:

Gender Identity Other:

Preferred Pronoun:

Preferred Pronoun other:

Cell Phone Number:

Home Phone Number:

Work Phone Number:

Email Address:

Alternate email:

Preferred method for maintaining communication?

How many people live in your household?

Number of children ages 6-18?

Number of children ages 5 and under?

Sign-up to receive general email communications from the Children's Defense Fund

Contact Person's Last Name:

First:

Middle:

Is this person authorized to pick up the child(ren) you enrolled in the program?

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Please list other adults who are authorized to pick up the child(ren) you enrolled in the program. Please include name, relationship and mobile number:

For example,
Jan Doe
Aunt
(555) 555-5555

I hereby agree to indemnify and hold harmless and blameless the Children's Defense Fund, Third Baptist Church of SF, Third Baptist Freedom Summer School, and its officers, employees or agents from any and all liability from damages, loss or injuries, either to the person or property, which the said minor may sustain while engaged in any activity conducted by or in connection with the Third Baptist Freedom School including but not limited to transportation. I further certify that I have legal custody by reason of the fact that I am the parent or the legal guardian by court order. I further allege that the said minor is physically able to participate in the activity set forth therein.

I hereby agree to authorize the Third Baptist Freedom School to use photographed or video graphed images of my scholar in brochures, flyers, pictorial displays, or other promotion for all purposes without compensation from their program, Third Baptist Church nor the Children's Defense Fund.

I give permission for my scholar to participate in any and all field trips taken by his/her class. I understand that TBFS will notify me in advance of the field trip activity, location, and the time. During these trips the TBFS provides transportation, my scholar will be secured by a seat belt, harnessed car seat, or booster seat. I will provide the necessary safety seat to be used for my scholar.

I further agree to reimburse or make good any loss or damage or costs that the Third Baptist Freedom School may have to pay if any litigation arises on account of any claim made by said minor, or anyone in said minors' behalf, resulting directly or indirectly from said minors' participation in the Third Baptist Freedom School program.

I further agree in case of injury or illness or other actions requiring parental permission, the Third Baptist Freedom School staff shall have the authority to act for us in case we cannot be reached. I further understand that in case of injury, serious illness, or in extreme cases of disciplinary action, the Third Baptist Freedom School Staff will, if need be, send home my son/daughter by first available transportation for their safety. I therefore willfully accept any and all expenses incurred to support that emergent need for my child/scholar.