IGW Participant Paperwork

Child's Information

Child's Name(Required)

First Last

Child's School(Required)

Child's Grade(Required)

Preferred Language at Home(Required)

Address(Required)

Street Address Address Line 2 City State

Caregiver's Information

Caregiver's Name(Required)

First Last

Relationship to Participant(Required)

Caregiver's Email(Required)

Enter Email Confirm Email

Caregiver's Phone Number(Required)

Preferred Method of Contact(Required)

Consent(Required)

I consent to receive communication about the program via phone, text, and email.

Add a Second Caregiver?

Second Caregiver's Information

Caregiver's Name(Required)

First Last

Relationship to Participant(Required)

Caregiver's Email(Required)

Enter Email Confirm Email

Caregiver's Phone Number(Required)

Preferred Method of Contact(Required)

Consent(Required)

I consent to receive communication about the program via phone, text, and email.

Emergency Contacts

In the even you can not be reached we will reach out to the contacts in order. Use the plus button (+) to add up to 4 emergency contacts

Name

Phone Number

Relationship to participant

Authorized Pick-Up & Transportation Plan

Transportation will be coordinated for participants from school to program sites. Participants need to be picked up at the end of the program each week (see attached schedule).

How will your child get home from the program?(Required)

Consent(Required)

If walking home, I give permission for my child to walk home independently.

Authorized Adults for Pick-Up (other than caregivers):

Use the plus button (+) to add up to 4 Authorized Adults.

Name

Phone Number

Relationship to participant

Are there any custody restrictions or court orders we should be aware of?

You selected yes, please explain (documentation may be required):

Medical & Safety Information

Does your child have any allergies?(Required)

Description of allergies(Required)

Does your child have any medical conditions (asthma, diabetes, seizures, etc.)?(Required)

Description of medical conditions(Required)

Is your child currently taking any medications during program hours?(Required)

Description of medications(Required)

Are there any mental health considerations, sensitivities, triggers, or accommodations staff should be aware of, to best support your child?

Child Interests & Goals

What are your child’s interests (activities, hobbies, topics they enjoy)?

Why does your child want to join this program?

Demographic Information

Child's Gender Identity(Required)

Is the participant eligible for Free or Reduced-Price Lunch?(Required)

Is the participant Latinx?(Required)

Race (select one or more)(Required)

Consent and Permissions

Release of Information Authorization

I authorize the Inspire Girls Wellness Program to discuss and/or disclose information regarding the above-named participant with the following community partners and funders:

The New London Community Recreation Center
New London Recreation
the Garde Arts Center
Justice Education Center
Your child’s academic institution (one of the following)

Regional Multicultural Magnet School
Bennie Dover Jackson Middle School
C.B. Jennings International Elementary Magnet School
New London High School
Nathan Hale Arts Magnet School
Winthrop STEM Elementary Magnet School

Purpose:

Coordination of services, program implementation, reporting, funding compliance, and evaluation of program outcomes.

Information to shared may include:

Participant name and date of birth
Attendance records
Participation and engagement information
Program outcomes and progress data
School affiliation and grade level
Relevant demographic information collected for reporting purposes

Information shared will be limited to what is necessary to fulfill the purposes described above and will be handled in accordance with agency policy and applicable confidentiality standards.

I understand that:

I may revoke this Authorization at any time by providing written notice to program staff.
Unless otherwise revoked, this Authorization will expire one year from the date of signature below.
Information disclosed pursuant to this Authorization may be subject to redisclosure by the receiving organization and may no longer be protected by the same confidentiality standards once released.

Please indicate your authorization below:(Required)

I authorize the release of participant information as described above.

I do not authorize the release of participant information.

Informed Consent for Participation

I understand and agree that:

The Inspire Girls Wellness Program provides enrichment, skill-building, and supportive programming as described by program staff. Program activities, expectations, and support will be communicated throughout the program year.
Program staff do not dispense medication.
All program staff are mandated reporters. If there is reasonable suspicion of abuse, neglect, or risk of harm to the participant or others, staff are required by law to report concerns to appropriate authorities.
The program operates during designated after-school hours only. In case of emergency, caregivers should contact 911 or appropriate emergency services.
Emergency Medical Consent: In the event of an emergency and I cannot be reached, I authorize program staff to seek emergency medical care for my child if necessary.
Caregiver engagement and communication with program staff support participant success.
I have the right to withdraw my child from the program at any time by notifying program staff.
Program staff may coordinate with school personnel and community partners, as authorized through a signed Release of Information, to support the participant’s success.
I consent to my child’s participation in program surveys, assessments, and evaluations used for program improvement, outcome measurement, and required reporting. Participation in surveys will not affect my child’s ability to participate in the program, and responses will be handled in accordance with agency confidentiality policies.

Consent(Required)

I acknowledge and agree to all of the above, including emergency medical consent.

Media Release Authorization

I hereby authorize Child and Family Agency of Southeastern CT, Inc. to photograph and/or video me and/or my child(ren), and to use photographs, video recordings, and/or submitted media for purposes including marketing, fundraising, advocacy, public education, and increasing awareness of CFA programs.

I understand and agree that:

Consent(Required)

Child and Family Agency of Southeastern CT, Inc. owns the information and all associated copyrights. CFA has the right to use the information, in whole or in part, and may edit or modify identifying details (such as names) to safeguard privacy.

I may choose whether my name or my child(ren)’s name is used in connection with any photographs, videos, or quotations.(Required)

Yes, I would like names to be used.

No, I do not want names used.

If no, how would you like to be identified in marketing materials (e.g., “Program Participant,” “Parent,” etc.)

If any direct quotes are to be used in print or publication, I understand that I will be asked for my explicit consent prior to use.(Required)

Yes

I understand that I am not required to sign this Media Release Authorization for my child to participate in CFA services or programs(Required)

Yes

I understand that photographs and videos used or disclosed under this authorization may be reused or redistributed by recipients and may no longer be protected under HIPAA privacy regulations.(Required)

Yes

I understand that I may revoke or discontinue this authorization at any time by providing written notice to the affiliate agency. Revocation will apply to future use of materials and will not affect materials already published or distributed.(Required)

Yes

Media Release Authorization Decision:(Required)

I authorize Child and Family Agency of Southeastern CT, Inc. to use media as described above

I do not authorize media use

Behavior & Participation Agreement

I understand that my child is expected to follow program rules and engage respectfully with staff and peers. I understand that unsafe or disruptive behavior may result in parent notification and removal from the program.(Required)

I acknowledge and agree.

Final Acknowledgement

By signing below, I certify that all information provided is accurate. I have read and understand this Registration & Consent Form, including Release of Information, Informed Consent (including Emergency Medical Consent), Media Release, and Behavior Agreement. I understand that failure to comply with program policies may result in dismissal.

This form remains in effect for the duration of enrollment unless revoked in writing.

Caregiver Name:(Required)

Caregiver Signature:(Required)

Date(Required)

MM slash DD slash YYYY