Summer Enrichment Camp 2023

Authorization for Emergency Medical Care

I understand that I will be notified at once in the event of an emergency with my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached or the emergency contacts cannot be reached to make the necessary arrangements or in a critical emergency requiring medical care, I authorize UNLEASHING POTENTIAL to seek emergency medical care. I understand that I am responsible for any costs associated with ambulatory/emergency medical treatment.
Parent Signature*

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Child's Physician *

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Phone Number*

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Preferred Hospital or Clinic
Hospital/Clinic Phone Number

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Please comment on child's social, emotional, and physical health.
My child takes medication that has to be administered throughout the day.*
Does your child have any allergies? If yes, please provide a copy of your child's Allergy Action Plan.*
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Does your child have asthma? If yes, please provide a copy of your child's Asthma Action Plan.*
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Does your child have an IEP or Behavior Plan? If yes, please provide a copy of your child's IEP or Behavior Plan.
Upload IEP or Behavior Plan

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Does your child have a one on one caregiver/paraprofessional throughout the school day?
I give permission for my child to be transported by Unleashing Potential for field trips.
Client Rights and Responsibilities

Special Note: Unleashing Potential has defined its “Client” as those Parents whose child (ren) receives services through our childcare and youth development programs, exclusive of young adults, ages 18 - 24.

Unleashing Potential (UP) Clients have the right to:

Ø Be informed of their rights and responsibilities

Ø Be provided with sufficient information to make an informed choice about using the organization and its services

Ø Fair and Equitable treatment including:

a. the right to receive services in a non-discriminatory manner

b. the consistent enforcement of program rules and expectations

c. the right to receive services that exemplifies dignity, respect, and is responsive to cultural and linguistic differences

Ø Be safe in the agency’s service environments

Ø Written and oral communication in the languages of the major population groups served

Ø The provision of, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known

Ø Participate in all service decisions; receiving service in a manner that is non-coercive and that protects the person's right to self-determination

Ø Request a review of their care

Ø Refuse any service and be informed about the consequences of such refusal, which can include discharge

Ø Receive a schedule of any applicable fees and estimated or actual expenses and are informed prior to service delivery about: the amount that will be charged; when fees or co-payments are charged, changed, refunded, waived, or reduced; the manner and timing of payment; and the consequences of nonpayment.

Ø Confidentiality and privacy re: services rendered unless a legal court order requests such information

Ø Be informed on how to lodge complaints or grievances

As a client of Unleashing Potential, I recognize my responsibility to:

Ø Participate in services specified in my plan including compliance with program rules and regulations.

Ø Not engage in violent or destructive behavior

Ø Honor the confidentiality of others during group activities

Ø Provide relevant information as a provision for receiving services and participating in service decisions

Unleashing Potential Administrative Office Hours are: 9am-5pm Monday- Friday
Signature for Client Rights Acknowledgement

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Media/Marketing Consent

I hereby authorize Unleashing Potential, on behalf of its affiliates or anyone authorized by Unleashing Potential, to take photographs, transparencies, film, video and/or audio recording, or any likeness of my child(ren).

I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, and social media.

I further authorize Unleashing Potential to use, distribute, publish, or telecast any of the works for the sole purpose of internal and/or external use by Unleashing Potential. I waive any interest in the material.

I understand I have the right to request the cessation of recording or filming. I also have the right to rescind consent for use up until a reasonable time before the recording or film is used.

I understand that no employee or agent of Unleashing Potential shall have any responsibility to monitor, supervise, or control any aspect of the photography or video recording or any subsequent use of such photographs or videos.

I hereby release Unleashing Potential, its agents, and employees from any liability for any and all claims arising out of the taking of photograph(s)/video(s) or any subsequent use thereof.
Signature for Media Consent

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Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Unleashing Potential during the before/after school program/ intercession or summer enrichment camp. In exchange for the acceptance of said child’s candidacy by Unleashing Potential, I assume all risks and hazards incidental to the conduct of the activities and release, absolve, and hold harmless Unleashing Potential, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected programs. In case of injury to said child, I hereby waive all claims against Unleashing Potential including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

I understand that the Summer Enrichment Program provided by Unleashing Potential is registered with the state of Missouri, however, it is exempt from licensure.
Signature for Participation Consent

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Will you need scholarship assistance?
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Summer Enrichment Camp 2023

Emergency contact and persons authorized to take child from facility other than parent ( at least one contact is required)

Authorization for Emergency Medical Care