STUDENT INFORMATION
Last name:
Date of birth:
Home address:
Participated in previous CIS Program:
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Yes
○
No
First name:
Grade level (Rising):
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6 th
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7 th
○
8 th
○
9 th
If yes, indicate:
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Race:
City/Zip:
School:
2014 Summer Camp
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Gender:
2014-15 Afterschool
CAMP INFORMATION
Please select the camps you are interested in attending:
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June 22-26 |
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June 29-July 3
PARENT/GUARDIAN INFORMATION
Name and Relationship (
Parent/Guardian 1
):
Address (if different):
Email: Phone:
Employer/Occupation:
Phone:
Name and Relationship ( Parent/Guardian 2 ):
Address
(if different): Employer/Occupation:
Email: Phone: Phone:
Child primarily lives with (check all that apply):
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Mother
○
Father
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Guardian
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Grandmother
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Grandfather
Please list any other adults in the home:
Language spoken at home:
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English
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Spanish
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Other:
EMERGENCY CONTACTS
Name:
Name:
Pediatrician and Phone:
Phone:
Phone:
Relationship:
Relationship:
Hospital preference:
TRANSPORTATION INFORMATION
○
My child will use bus transportation.
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My child will be picked up by an approved individual.
Would you like to add anyone to the approved pick up list (other than Parents/Guardians, adults in home, and emergency contacts)?:
Name: Phone: Relationship:
Name: Phone:
SPECIAL CONSIDERATIONS
Relationship:
Medications with schedules:
Allergies:
Emotional, behavioral, intellectual, or physical needs (please describe):
*Optional* Special circumstances/requests (please include any special family or background circumstances that you would like to share):
My child is on free/reduced lunch during the school year.
○
Yes
○
No
PARENT/GUARDIAN SIGNATURE
I certify that the information provided is correct:

Please read and sign this contract with your child. This contract must be turned in with the application.
RELEASE AND HOLD HARMLESS | ASSUMPTION OF RISK | EMERGENCY MEDICAL TREATMENT
In consideration for my child’s participation in CIS Orange programming, I release, hold harmless, and forever discharge CIS Orange, their employees, and agents from any and all liability, claims, actions, and causes of action whatsoever arising out of or related to any loss, property damage, or personal injury, including death, that may be sustained by me or my child or to any property belonging to me or my child while my child is participating in CIS Orange programming, except for damages caused by the negligence of the CIS Orange and/or their agents or employees. I am fully aware of the risks and hazards associated with this program. My child’s participation in this activity is elected by me and not required. In the event of illness of injury, I authorize CIS Orange staff with current first aid certification to administer first aid to my child. I grant permission for emergency CPR to be administered to my child by a certified person should it become necessary. I authorize employee/agents of CIS Orange to obtain emergency medical treatment for my child at the nearest medical facility as deemed necessary, including administration of anesthetic or other medication and surgery, and I assume the cost of such treatment. This authorization is given in advance of any diagnosis, treatment, or hospital care being required, but is given to provide authority on the part of CIS Orange to give specific consent to the diagnosis, treatment, or hospital care which is the best judgment of a licensed physician is deemed advisable. I understand that CIS Orange will make best efforts to notify me immediately should emergency treatment for my child become necessary.
TRANSPORTATION | MEALS | ATTENDANCE | LATE ARRIVAL FEE
Transportation from CIS Orange Afterschool is provided by the school district for students who requested this service during registration.
Parents who pick up their children before the scheduled end time must come inside the school with a valid photo ID to sign out their children. Parents picking up students at the scheduled end time must be in the front of the school with a photo ID ready. Parents who choose not to use bus transportation are expected to pick up their children no later than 2:00 PM. There will be a late charge of $15
for each 30 minute increment, in part or in whole, past 2:00 PM. There will be a 5 minute grace period, so no late charges will be applied from 2:00-2:05 PM. A FREE breakfast and lunch will be provided to all students. Parents/Guardians must notify CIS Orange if their student has allergies as additional paperwork must be completed and on file. Parents/Guardians must disclose other known allergies, or emotional, behavioral, mental, or physical needs that will affect any student’s safety/participation in the program. Attendance is required and if my child is unable to attend the program the first two (2) days, their spot will be given to a child on the
waiting list. Exceptions are possible if the parent/guardian contacts the program director to communicate about the absences. Hours of operation for camp will be 9am-2pm, with optional transportation and breakfast service starting at 8:15am.
ACCESS TO CONFIDENTIAL INFORMATION| STUDENT BEHAVIOR AND DISMISSAL
CIS Orange will be granted access to PowerSchool and other confidential information regarding my child’s grades/scores, behavior, progress, and attendance. This information will be collected and shared with funding agencies of CIS Orange including the North Carolina
Department of Public Instruction and the national network of Communities In Schools affiliates. Data will be collected quarterly on students’ grades and behaviors. Student and parent feedback will be collected twice per year through anonymous surveys. Confidential student information concerning identity, academics, health, or behavior will only be shared with approved CIS staff or affiliates, as needed.
Students are expected to adhere to the same rules that apply during school hours. Major disruptions will not be tolerated and I may be asked to attend a meeting with CIS Orange or pick up my child during program hours if student behavior is unacceptable. CIS Orange reserves the right to dismiss a student when necessary for the best interests of the CIS program. In the case of behavior problems, CIS
Orange will host one informal coaching session with the student and document one written/phone/email warning to the parents/guardians before dismissing any student. If the behavior in question endangers another person, a student may be dismissed without a prior warning.
CIS does not tolerate acts of bullying, as per NCGA SB526 statute. Bullying is defined as a threat/act of harassment or harm against another person and/or their property based on, or perceived to be based on, differences in status or characteristics. Bullying can be reported anonymously online at cisorange.org, or using the paper forms given to students during programs.
EMERGENCY PREPAREDNESS AND RESPONSE
CIS Orange programs will follow the emergency plan as adopted by each school site. This policy covers issues by which to provide protection for each student’s safety and well-being. This recommendation includes each program site or Site Coordinator to contact the
CIS Orange central office personnel via central office number and/or staff’s mobile number (provided to all staff) to inform CIS Orange staff of the school or program’s problem. If necessary, the Executive Director will contact the Board Chair of pending problem. In all emergencies, CIS staff are to use best judgment to implement emergency procedures for the protection, safety, and well-being of the students and all persons involved. Emergencies can be called by the school district, principals, CIS Site Coordinators, or CIS Executive
Director, Program Director, or Program Officer, or by the appropriate local officials. Emergencies: For earthquakes and tornadoes, each site will follow school emergency plan to relocate to designated tuck-and-cover locations. For lightning, severe winds, and extreme temperatures, each site will follow school emergency plan so that students will not participate in outdoor activities, and programs will be cancelled in severe cases. For winter precipitation, power failure, and water failure, each site will follow school emergency plan and programs will be cancelled or end early. For events that cause potential danger to school grounds, such as, but not limited to fire and bomb threats, each site will follow school emergency plan to evacuate to designated safe place off-site and contact 911 immediately.
CIS Office and appropriate school admin should be contacted as soon as possible. For events that cause potential danger to persons in the building, such as, but not limited to active shooters, criminal threats, gang violence, and domestic violence, each site will follow school emergency plan to follow lockdown procedures and contact 911 immediately. CIS Office and appropriate school admin should be contacted as soon as possible. For events that cause potential danger to individual students, such as, but not limited to suicide threats and drugs, each site will follow school emergency plan so that CIS Site Coordinator or the appropriate staff will supervise the students and contact 911 immediately. Parents/Guardians, CIS Office, and appropriate school admin should be contacted as soon as possible.

Please read and sign this contract with your child. This contract must be turned in with the application.
ENROLLMENT PROCEDURES | SUPERVISION
CIS Orange programs are open to all students. Each student must have an application and a student/parent handbook contract completed and submitted to CIS Orange to be eligible. Students are admitted, first, on the needs of the family and students. These students are referred to CIS Orange by principals, teachers, social workers and counselors. Then, the remaining spots are filled on the first-come-firstserve order of the applications and schedule availability for all other students. We strive to serve students who require additional support due to financial, social, physical, or academic challenges. Students will always be supervised by an approved CIS adult during program hours; students will never supervise other students. All volunteers must complete a CIS orientation/training and pass a background check before working with students. CIS requires all individuals and institutions are required to report suspected child abuse/neglect, in accordance with state law. If child abuse is suspected, please contact Orange County Department of Social Services at: 919.245.2800 or
919.968.2000.
PHOTOGRAPH/VIDEO CONSENT
CIS Orange may photograph or videotape my child’s participation in the program and use images in brochures, publications, websites, audiovisual presentations, promotional literature, advertising, or for any other similar purpose for CIS Orange or for any of its third party affiliates without compensation to me or my child. Such photographs or images, and their reproductions, remain the property of CIS
Orange; I waive the right to approve the final product; and I release, and discharge CIS Orange agents and employees, from any and all claims and demands in connection with the use of said photographs and images, including but not limited to, any claims for invasion of privacy, appropriation of likeness, and defamation.
For Photo/Video for my child, I DO NOT CONSENT. _____ (optional initial).
INTERNET CONSENT
CIS Orange complies with both the 1998 Title XIII Online Privacy and the 2013 Children’s Internet Protection Acts. As such, sites: targeted at children cannot use deceptive practices to collect personal information; must take reasonable steps to verify parental consent before collecting or using personal data; with content that is deemed inappropriate for children are blocked, limited, and/or filtered. As part of CIS Orange programs, staff provides access to age-appropriate educational websites, consistent with the goals of the program. My child is allowed to access the Internet as part of the program. While CIS Orange has taken steps to limit access to the
Internet on the computers used for the program, and my child will only have access to the Internet while CIS Orange staff are present,
I recognize that it is not possible for the program staff to fully monitor and control the online material to which my child may have access while participating in program, and I release CIS Orange and their agents and employees from any responsibility related to any non-program directed/authorized websites which my child may access while participating in the program, or consequences thereof.
For Internet use for my child, I DO NOT CONSENT. (optional initial).
FIELD TRIPS
A field trip could be scheduled one day during camp. Participants could be off site from 9:30am-1:30pm. If a possibility, more details will be provided. If I need to pick up my child early, I will make other arrangements with the CIS Program Director at least 4 days before the field trip. The trip will be educational and supervised by CIS staff. Transportation will be provided. Other informal trips may be taken within the walking distance of the normal camp site. I consent to my child’s participation in CIS field trips.
For Field Trips for my child, I DO NOT CONSENT. (optional initial).
SIGNATURES
I have read and understand this document. I understand and agree that it is binding on myself, my child, and personal representatives.
I also certify that all information I entered during the registration process is true and accurate.
Student Name:
Student Signature:
Date:
Parent Name:
Parent Signature:
Date: