Section 1 Child/Youth Name* First Middle Last
Child/Youth Gender* Child/Youth Race/Ethnicity (please select only one)* Mark all languages your child/youth speaks Child/Youth Current Grade Level* (for summer, select the last grade completed - please select only one)
No M-DCPS ID #
Home Address* Caregiver Name* First Last
Is this a cell/mobile phone? Caregiver preferred language for contact from The Children’s Trust (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.
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.
What conditions does your child/youth have that are expected to last for a year or more? (mark all that apply)* What are the main ways in which your child communicates? (mark all that apply)* What, if any, help does your child/youth receive at this time? (mark all that apply)*
Section 3 - Medical Information Does your child have any current conditions, which would limit or deter participation in this program?* Child’s allergies, disabilities, medications, or dietary restrictions (Special Instructions), if any:*
Emergency Information If I cannot be reached, please try to contact my designated alternate(s):
Section 4 - HIPAA Announcement
Section 5 - Non-Discrimination Policy: Religious Instruction Permission (Leave unchecked if not given) Give consent
for my child’s participation in optional religious instruction activities.
Section 6 - Parental Consent 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.
Authorization for photography/video 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.
Transportation Agreement Arrival to the site: Check all that apply: Pick-up from the site: (Note: A child that is usually picked up will not be allowed to walk home unless the parent notifies the program in advance)
If applicable, I give permission for my child to be transported by Gang Alternative, Inc. provided transportation. Yes
List of people who may pick up my child:* Please click the "plus" icon to add more people.
Section 7 - Client’s Rights
Section 8 - Parent Acknowledgement 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.*
Section 9 - Liability Waiver
Section 11 - Rules of Conduct for participants 6th-12th Grade
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? Please check all that apply: Does your child have a diagnosis or condition that affects behavior, communication, learning, or social interaction that program staff should be aware of Does your child require one-on-one support or behavioral assistance during the school day? Has your child ever been suspended or removed from an afterschool or childcare program because of behavior? 
