» BLOC After School Program 6-12 Form

BLOC After School Program 6-12 Form Participant Information Form for 2026-2067

Enrollment for Gang Alternative’s BLOC Afterschool Program (Grades 6–12) is now open.

This application is for students who attend the following schools:

Horrace Mann Middle School
North Miami Middle
Hubert O. Sibley (K-8)
Morningside (K-8)
Edison Park (k-8)
Miami Edison High
North Miami High
William H Turner Tech
West Homestead K-8
Homestead Middle School

Program sites are:

6620 North Miami Ave (middle schoolers);
North Miami High Schol (high schoolers);
Phichol Williams Center (middle schoolers)

Please note that submitting this application does not guarantee acceptance into the program. Families will be notified if their child is selected for enrollment.

"*" indicates required fields

Section 1

Child/Youth Name*

First Middle Last

Child/Youth Date of Birth*

Child/Youth Gender*

Male

Female

Prefer not to answer

Child/Youth Race/Ethnicity (please select only one)*

Mark all languages your child/youth speaks

English

Spanish

Haitian Creole

Other

Please state

Child/Youth Current Grade Level*

(for summer, select the last grade completed - please select only one)

Specify

Miami-Dade County Public Schools ID# (all students attending public or charter schools must have a school ID#)

Current School*

Home Address*

Street Address City ZIP / Postal Code

Caregiver Name*

First Last

Caregiver Phone Number*

Is this a cell/mobile phone?

Yes

Caregiver Email address*

Caregiver preferred language for contact from The Children’s Trust

English

Spanish

Haitian Creole

(please select only one)

Please note that The Children’s Trust may contact you via postal mail, email and/or text to ask about your satisfaction with services, and to make you aware of other Trust-funded programs, initiatives and events that may interest you.

How did you hear about this program?*

Signature*

As part of my child’s voluntary participation in this program, I give my permission for the information collected through this program to be submitted to The Children's Trust for program evaluation and quality purposes. The Children’s Trust provides funding for the program to operate and follows strict data privacy protections for the information collected (for example, following the Family Educational Rights and Privacy Act/FERPA guidelines).

Date Signed*

Section 2

We want to get to know your child better so that we can provide the best possible experience in our programs. The questions on the next page address your child's need for assistance, any conditions or challenges, their communication methods, and the support they receive. This information is used to ensure that children and youth of all abilities are welcomed and supported in programs funded by The Children’s Trust.

To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?*

If you noted any areas of extra assistance needed, please be sure to speak individually with the program staff about your child’s needs and how the program can meet them.

Specify

What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)*

Please specify

What are the main ways in which your child communicates? (mark all that apply)*

Speaks and is easily understood

Uses gestures or expressions like pointing, pulling, smiling, frowning, or blinking

Speaks but is difficult to understand

Uses sounds that are not words like laughing, crying, or grunting

Uses communication devices like pictures or a board

Uses sign language

What, if any, help does your child/youth receive at this time? (mark all that apply)*

Behavioral therapy or services

Occupational therapy (OT)

Counseling for emotional concerns

Physical therapy (PT)

Daily medication (not including vitamins)

Speech/language therapy

Exceptional student education services in school through an IEP or 504 plan

At least one of these services are needed but not received

If you are interested in other community services or resources, you can call the 211 Miami Helpline, visit 211miami.org, or learn more about The Children’s Trust programs at www.thechildrenstrust.org. For special needs resources for individuals with disabilities and their families, visit www.advocacynetwork.org/services/individual-family-support or www.thechildrenstrust.org/cwd.

Section 3 - Medical Information

Does your child have any current conditions, which would limit or deter participation in this program?*

Yes

Please explain

Are there any specific, conditions that prohibit your child from participating in activities, such as sporting events, field trips, etc.?*

Child’s allergies, disabilities, medications, or dietary restrictions (Special Instructions), if any:*

Emergency Information

Physician’s Name*

Physician’s Phone*

Name of Insurance

Group #

Member #

If I cannot be reached, please try to contact my designated alternate(s):

1 Name

1 Relationship

1 Phone Number

2 Name

2 Relationship

2 Phone Number

Signature*

I hereby certify that the information provided above, is both true and accurate. I give permission to the staff/personnel of Gang Alternative, Inc. to take my child to the hospital for treatment (in the event that Rescue/911 determines that the need to transport is unnecessary but medical attention is needed immediately), if I am unable to be reached.

Date*

Section 4 - HIPAA Announcement

Signature*

This HIPAA Notice of Privacy Practices provides information about how Gang Alternative, Inc. may use and disclose protected health information about you. You have the right to review this notice before signing this acknowledgment. By signing this form, you acknowledge and consent to our use and disclosure of protected health information about you for treatment, payment and health care operations, you have the right to revoke this consent, in writing, except where Gang Alternative, Inc. has already made disclosures in reliance on your prior consent.

Section 5 - Non-Discrimination Policy:

Section 6 - Parental Consent

By signing the application below, I agree and certify the following:

I acknowledge that the application information and medical information I have provided above is true and complete to the best of my knowledge and ability.
I understand that participation by my children in any program sponsored by Gang Alternative, Inc., its partners and funders may involve physical education, organized sports, meals, and off-site field trips. As these activities may carry some degree of risk to my child’s physical and emotional health, I hereby release, hold harmless and waive all claims associated with activities from Gang Alternative, Inc., its partners, funders and all employees, officers, directors, agents, and volunteers associated with Gang Alternative, Inc.
I agree to make every effort to insure that my child participates in the program on all scheduled days, unless he/she is too ill to attend. I also agree that I or my designated representative will sign-out my child every day they attend the program.
I agree to all the program standards.
I understand that the program site may be on the premises of a religious institution for the primary purpose of providing academic enrichment and a safe environment. In some cases, religious instruction may be offered as an option to the children on the premises, but only with written parental permission. Unless express written permission has been given for my child to participate in religious instruction, an optional non-religious activity will be conducted.

Parent/Guardian Signature*

Date*

I (state name)*

authorize my child*

to participate in Gang Alternative's prevention program which includes participating in program evaluation activities as needed in order to learn how to improve services at Gang Alternative. My child may be asked to fill out surveys or engage in a group discussion along with other children about their experiences in the program. My child will be identified with an ID number during the group discussion and not with their names to maintain confidentiality. These group discussions may include questions relating to sensitive topics, such as substance use among youth. My child has the right to refuse participation for these activities at any time. Any youth who experiences discomfort while participating will be encouraged to speak to a Gang Alternative staff member for additional services if needed. I understand that I may revoke this consent in writing any time before any action is taken by Gang Alternative based on this consent. I further understand that this consent will end when the grant expires.

Parent/Guardian Signature*

Date*

Authorization for photography/video

the parent or guardian of*

hereby consent and authorize the staff of Gang Alternative, Inc. to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings (hereinafter “Recordings”) of me, my children, or my wards for educational, research, documentary, and public relations purposes. Any such recordings may reveal your identity through the image itself without any compensation to you, your children, or wards. With regard to the use of any recordings taken of you, your children or wards, you hereby waive any and all present and future claims you may have against Gang Alternative, Inc., their staff, service providers, employees, agents, affiliates and Board members.

Parent/Guardian Signature*

Date*

Transportation Agreement

Arrival to the site: Check all that apply:

By bus/van

By walking

With authorized person/relative

With Parent/Guardian

Pick-up from the site:

Walk home

Take the bus/van

Pick-up by authorized person/relative

Pick up by Parent /Guardian

(Note: A child that is usually picked up will not be allowed to walk home unless the parent notifies the program in advance)

List of people who may pick up my child:*

Please click the "plus" icon to add more people.

Name

Relationship

It is my responsibility to make sure my child is picked up and/or receives access to our home by either a responsible adult or myself. Should any changes occur, I will notify Gang Alternative, Inc. immediately.*

Date*

Section 7 - Client’s Rights

As an individual, and as a participant of Gang Alternative, Inc. program, you have rights. We, the professional staff, recognize and respect these rights. Each participant in Gang Alternative, Inc. program is entitled to the following rights;

You have the right to appropriate and quality services.
You have the right to give informed consent or refuse services.
. We recognize and respect your dignity as an individual and human being.
You have the right to protection of confidentiality of any personal identifiable information without written consent as governed by local, state, and federal regulations, except when there is reasonable concern for child abuse, suicide, homicide, or retaliation.
You will not be the subject of experimental or investigative research without prior written and informed consent.
We will not release any information about you without written permission from you or your guardian, or a court order.
You have the right to actively participate in periodic reviews of an individualized service plan.
You have the right to humane treatment free from abuse, neglect, and exploitation.
We will encourage and assist you to understand and exercise your right to voice grievances and recommend changes in policies and services to staff.
You have the right to receive a copy and a complete explanation of client’s rights clear, non-technical terms anda language the client understands.

HOW TO FILE A COMPLAINT IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED: If you believe your rights have been violated, please submit your complaint in writing to:

Corporate Compliance Officer Gang Alternative, Inc. 12000 Biscayne Blvd. Ste. 402 North Miami, FL 33181 (786) 391-2375

You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Parent/Guardian Signature*

Date*

Section 8 - Parent Acknowledgement

have also received in writing the disciplinary practices used by this child care facility.

Florida Abuse Hotline Report:

By phone 1-800-962-2873 or TDD 1-800-453-5145
By fax 1-800-914-0004
http:/www.dcf.state.fl.us/abuse/report/
Substance Abuse and Mental Health Hotline 305-377-5029
By fax 1-800-914-0004
https://reportabuse.dcf.state.fl.us

I also acknowledge that I have received and have read, with complete understanding the parent handbook which explains the expectations, policies and procedures of Gang Alternative, Inc.*

Paper Copy

Parent/Guardian Signature*

Date*

Section 9 - Liability Waiver

The individual(s) named below (referred to as "Participant(s)") desire to participate in programs and related events and activities (the "Activity") provided by GANG ALTERNATIVE, INC., a Florida corporation with an office located at 12000 Biscayne Blvd, Ste. 402, North Miami, FL 33181 (the "Company"). In consideration of being permitted by the Company to participate in the Activity and in recognition of the Company's reliance hereon, Participant(s) agree to all the terms and conditions set forth in this instrument (this "Waiver").

Participant(s) acknowledge and fully understand that each Participant may be exposed to or engaged in activities that inherently involve risk of serious injury and accidents. Accidents can be the results of the nature of the Activity and can occur with or without any fault of the Participant, the employees, agents, other participants, or anyone else at the facility where the Activity is taking place. By allowing their child(ren) to participate in the Activities and/or by participating in the Activities, each Participant accepts the risk of accident occurring, and agrees that the Activities, as described above, are suitable for each Participant.
Participant(s) assume all the foregoing risk associated with the Activity and accept personal responsibility for the damages following such injury in connection with the Activity.
Participant(s) release, waive, discharge, hold harmless and covenant not to sue Gang Alternative, Inc., Program Sites, Event Sites, Program Funders, and School Boards (MDCPS, BCPS) any affiliated entities or clubs, their respective administrators, directors, agents, coaches, and other employees/agents, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessees of the facility or premises used to conduct the Activity, all of which are hereinafter referred to as "Releasees" from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise.
Participant(s) hereby consent to the administration of medical treatment deemed necessary if any Participant is injured or requires medical attention during participation in the Activities. Participant(s) understand and agree that Participant(s) are solely responsible for all costs related to such medical treatment and any related medical transportation and/or evacuation. Participant(s) hereby release, waive, discharge, hold harmless and covenant not to sue the Releasees from any claim based on such treatment or other medical services.

This Waiver constitutes the sole and entire agreement between the Company and Participant(s) with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this Waiver is held invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Waiver or invalidate or render unenforceable such term or provision in any other jurisdiction. This Waiver is binding on and shall inure to the benefit of the Company and Participant(s) and their respective heirs, successors, and assigns. All matters arising out of or relating to this Waiver shall be governed by and construed in accordance with the laws of the State of Florida without giving effect to any choice or conflict of law provision or rule (whether of the State of Florida or any other jurisdiction). Any claim or cause of action arising under this Waiver may be brought only in the federal and state courts located in Miami-Dade County, Florida and Participant(s) hereby consent to the exclusive jurisdiction of such courts.

BY SIGNING, PARTICIPANT(S) ACKNOWLEDGE THAT PARTICIPANT(S) HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS WAIVER AND THAT PARTICIPANT(S) ARE VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE COMPANY. PARTICIPANT(S) ACKNOWLEDGE THAT PRIOR TO SIGNING THIS AGREEMENT, PARTICIPANT(S) HAD THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY TO REVIEW THIS AGREEMENT. EACH PERSON SIGNING BELOW IS AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT.

Name of each Participant*

Signed*

Printed Name*

Date*

Signed*

I am the parent or legal guardian of the minor(s) named above. I have the legal right to consent and, by signing below, I hereby consent and agree to the terms and conditions of this Waiver.

Printed Name*

Date*

Section 10 - Discipline Policy for participants K-5th Grade

(If student is in grade 6-12, skip to the next page)

We are required by the Department of Children and Families to provide parents with a written discipline policy.

Our program will ensure that age-appropriate, constructive disciplinary practices are used for your child. This care will allow the child time to look over his or her behavior. We will encourage children to choose alternatives to improper behavior. To insure a safe and successful program, discipline is a must. We welcome the ideas of parents, so feel free to share them with us. The following steps will be used for behavior modification:

1st – Children will be corrected and asked to change their behavior.
2nd – Children will be re-directed from situation.
3rd – Children will be placed on “Time Out”.
4th – Parents will be contacted if behavior is not corrected.
5th – Children shall not be subjected to discipline which is severe, humiliating, or frightening.
6th – Discipline shall not be associated with food, rest, or toileting.
7th – Spanking or any other form of physical punishment is prohibited.
8th – Children may not be denied active play because of misbehavior.

All childcare personnel must comply with the facility’s written disciplinary policy.

have received in writing the disciplinary practices used by this child care facility.

Signature of Parent or Guardian*

Name of Child*

Date*

Section 11 - Rules of Conduct for participants 6th-12th Grade

I will be courteous to and RESPECTFUL of all staff and other youth.
I will be a good listener:
- a) One person speaks at a time. I will raise my hand to speak
- b) When someone is called on, I will listen.
- c) When an adult is speaking, I will listen.
I will attend and be active in the program.
I will dress appropriately.
I will keep my hands and objects to myself.
I will not bully ANYONE in or outside the program.
No name calling, hitting, or non-cooperation and no use of profanity
I will not bring any tobacco, alcohol, or medicine to the program.
Required medicine must be approved by the Staff.
No GANG violence / fighting. NO GUNS or KNIVES.
I will be responsible for my own property,(ie. Jewelry, games, cameras and phones)
I will stay with staff at all times. I will not leave the site without an adult staff member.
I will notify staff IMMEDIATELY of injury, sickness, or personal problem.

I understand that there are some actions that will not be tolerated because they are harmful or against the law. Therefore, I understand that I can be sent home from the program for:

Bringing weapons, alcohol, tobacco, or other drugs
Dangerous actions
Fighting
Being unable to obey any of the other Rules of Conduct above

The Program Coordinator will inform my parent or guardian of my dismissal. I will be kept under Gang Alternative, Inc. staff supervision until I can be picked up by or delivered to my parent or guardian.

Name of Youth*

Youth’s signature:*

Date*

Parent’s signature*

Date*

Section 12 - To help us provide a safe and supportive environment, please answer the following questions:

Does your child currently receive any special education, behavioral, or therapeutic services at school?

Yes

Please check all that apply:

Registered Behavior Technician (RBT) Behavior Intervention Plan (BIP) Individualized Education Program (IEP) Section 504 Plan

Speech Therapy

Occupational Therapy

Physical Therapy

Counseling/Mental Health Services

Other

Please specify

Does your child have a diagnosis or condition that affects behavior, communication, learning, or social interaction that program staff should be aware of

Yes

Please describe

Does your child require one-on-one support or behavioral assistance during the school day?

Yes

Please explain:

Are there specific behaviors or triggers that our staff should know about to help your child succeed?

What strategies or accommodations work best for your child?

Has your child ever been suspended or removed from an afterschool or childcare program because of behavior?

Yes

Please explain:

Is there anything else you would like us to know to help ensure your child's success and safety?