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Dear Parent/Guardian,
If a student becomes sick or injured at school, it may become necessary to provide the student with over-the-counter medication for symptom relief. Limited medications needed for temporary illness, on a short-term basis are available in the Nurse’s office. This form authorizes the Nurse or other authorized personnel to administer medication to your child. This form is only for the medications listed below and will only be administered per manufacturer’s recommended dosing. This form will remain in effect until the last day of summer school/camp.
(Note: Household income information is confidential and will NOT be shared with third parties. Our program requests this information to better serve and assess the needs of our program participants.)
Roles, Responsibilities and Commitments for Parents, Guardians and Families
I, (Parent/Guardian), understand that the Wise Readers to Leaders program uses models, curriculum, and training which seeks to ensure every child a successful passage to adulthood with the help of caring families and communities. I understand that a key goal of the Wise Readers to Leaders program is to involve parents in the life of the program as active participants in the learning experiences of their children.
I understand that all adults, including parents, guardians, and adult family members of children enrolled in the Wise Readers to Leaders program, are expected to be positive role models, to communicate the importance of academic achievement, and to contribute to the creation of a caring and nurturing learning environment in which every child is valued and seen as capable of achieving.
o I agree that during the time my child/children is/are enrolled in the Wise Readers to Leaders program, I will:
I, (Parent/Guardian), give permission to Wise Readers to Leaders and its designees to collect and record data on my child/children. This data gathering may include, but is not restricted to, the following:
I understand that the purposes of these surveys and interviews are to document the impact of the Wise Readers to Leaders program on its participants and to identify areas for improvement. I also understand that this information will remain private, and that only my child's/children's site director(s) and research assistants approved by the Wise Readers to Leaders program will be able to look at his/her/their responses.
I also understand that my child’s/children's responses will be automatically grouped together with the responses of all Wise Readers to Leaders sites for any public presentations of findings, and that my child/children will not be individually linked to his/her/their responses. In addition, I understand I can take back my permission at any time.
I hereby authorize and irrevocably grant to the Wise Readers to Leaders and its affiliates, licenses, agents and assigns:
I waive any inspection or approval of the media or any advertising or publicity in which my child's/children's or my name, voice, appearance, likeness, narrative, or comments might appear. I expressly release and agree to hold harmless Wise Readers To Leaders and its agents, employees, licenses and assigns from and against any and all claims including, but not limited to, invasion of privacy that I might ever have in any way relating to any of the aforementioned uses.
Our program is very fortunate to have a counseling program available for enrolled students. We are happy to have counseling interns and trainees from The Maple Counseling Center available to work with our students. The interns and/or trainees will be meeting with students individually, in small group sessions, and/or in the classroom settings to assist children with learning how to improve social interactions, enhance conflict resolution skills and address issues of self-esteem. All interns and trainees are supervised by a licensed therapist, who will be providing regular oversight and training to insure a quality experience for the students.
Your child’s privacy is important. Therefore, we have implemented safeguards to ensure that it is protected. California law requires adherence to reasonable expectations of privacy in certain counseling situations. However, when there is a reasonable suspicion of child abuse, elder or dependent adult abuse, or when the client threatens violence to an identifiable victim, the privacy of the client can no longer be honored. Additionally, confidentiality and/or privacy may be broken if a client presents to be a danger to him/herself.
Finally, counseling services are being offered by our program with the understanding that the counselor and essential program personnel will be sharing client information when appropriate. A copy of our Privacy Policy will be issued or is available upon request. Please be advised that your child’s therapist is a pre-licensed counselor who will be consulting regularly with his/her licensed supervisor.
If you have any questions regarding privacy, confidentiality, or the nature of the counseling services consented to in this agreement, please feel free to contact us.
Sincerely,
The Wise Readers to Leaders Staff By signing below, I hereby attest and affirm that I give express informed consent for the above-named child (“Client”) to participate in, undergo, or to receive counseling services administered by therapist(s) of The Maple Counseling Center. I reserve the right to revoke consent at any time by written notification to the Wise Readers to Leaders program. By signing below, I hereby attest and affirm that I am the Parent/Legal Guardian of the above-named child (“Client”) and have full legal right to grant consent to the provision of counseling services. Moreover, to the best of my knowledge, such consent does not require mutual parental consent under state law, federal law, or a court-ordered child custody decree.
In consideration of the Scholar/s named in this application (the “Scholar/s”) being permitted to participate in Wise Readers to Leaders (“WRTL” or the “Program”), the undersigned, parent(s), or legal guardian(s) of the Scholar/s, on behalf of our heirs, executors, administrators and assigns, and the Scholar/s, hereby agree to the following terms and conditions set forth below:
Participation: I/We give permission for the Scholar/s to participate in the Wise Readers to Leaders program through the full calendar of programming.
Expectations: I/We understand and acknowledge that the Scholar/s is/are expected to abide by all WRTL/Stephen Wise Temple/Milken Community Schools/American Jewish University/Wilshire Boulevard Temple/Leo Baeck Temple and any future site partner's (collectively referred to herein as "SITE PARTNERS") regulations during the course of the Program. I/We agree that WRTL has the right to terminate the Scholar’s participation in the Program for any behavior deemed detrimental to the Program or the Scholar.
Hold Harmless: I/We acknowledge that as a condition of the Scholar/s participating in the WRTL Program, I/We hold harmless and waive any and all claims against Wise Readers to Leaders (“WRTL”), Stephen Wise Temple (“SWT”), Milken Community Schools ("MCS"), American Jewish University ("AJU'), Wilshire Boulevard Temple (WBT), Leo Baeck Temple (LBT) and all future site partners, and its officers, employees, agents, and volunteers, including, but not limited to, claims arising out of any ordinary negligence of any officer, employee agent, or volunteer of the WRTL and SITE PARTNERS for any injury, accident, illness, or death, or any loss of damage to personal property occurring during or by reason of the Scholar participating in the Program, unless claim is based on gross negligence.
Voluntary Release of All Claims: I/We voluntarily release, discharge, waive and relinquish all claims that each may have against WRTL and SITE PARTNERS and, its staff, agents, employees, representatives, successors, and assigns (collectively the “Releases”), arising out of or in any way related to the Scholar’s/Scholars' participation in the Program, including, but not limited to, claims for bodily injury, personal injury, emotional distress, property damage or wrongful death occurring to the Scholar/s arising out of his/her/their involvement in the Program. This release, discharge, waiver and relinquishment also pertains to any instruction or supervision related to the Program on the part of WRTL, its officers, directors, trustees, employees and agents, unless claim is based on gross negligence.
Medical Care: I/We consent to any of the staff, employees, agents and representatives of SWT and WRTL administering or consenting to the administration of such emergency medical care to the Scholar/s as such person deems appropriate in the circumstances, and hereby authorizes medical treatment in case of emergency.
Medical Insurance: I/We understand and acknowledge that WRTL does not carry or maintain health, medical, or disability insurance coverage for the Scholar/s and therefore agrees to assume the responsibility for such insurance coverage on the Scholar/s.
Severability: If any provision of this agreement is held invalid or unenforceable, the remainder of this agreement shall nevertheless remain in full force and effect. If any provision is held invalid or unenforceable with respect to particular circumstances, it shall nevertheless remain in full force and effect in all other circumstances.
Voluntary Agreement: The Scholar/s and the parent(s)/guardian(s) acknowledge that they have read this Release and are aware of the legal consequences of signing this binding document. My signature below indicates that I have read and freely signed this agreement. I further certify that I am legally competent to sign this agreement.
IMPORTANT – READ ENTIRE AGREEMENT BEFORE SIGNING
I, the undersigned parent or legal guardian of relevant Scholar/s, consent to any of the staff, employees, agents and representatives of WRTL administering or consenting to the administration of such emergency medical care to the Scholar/s as such person deems appropriate in the circumstances, and hereby authorizes medical treatment in case of emergency.
I further authorize release of medical records and/or information pertaining to the diagnoses or treatment of the above-named Scholar/s when such disclosure is necessary for the purpose of evaluation, treatment or emergency care.
This form will remain in effect through the full calendar of programming.
Drop-off and Pick-up:
Stanley Mosk children must be brought to Stanley Mosk Elementary School each morning, Fullbright children must be brought to Fullbright Elementary School each morning, Garden Grove children must be brought to Garden Grove, LA Elementary children must be brought to LA Elementary School each morning and Reseda Elementary students must be dropped off at Reseda Elementary. Scholars must arrive at each Elementary School in the morning by 7:30 a.m. to ride the bus to the child’s particular Wise Readers to Leaders campus. All middle school scholars must be brought to Stanley Mosk Elementary School or Garden Grove Elementary School each morning to ride the bus to the American Jewish University campus. Please be sure your child boards the correct bus to his/her campus. Parents must park and bring their child/children to the bus and sign them in. No exceptions.
Children must be picked up from Stanley Mosk, Fullbright Garden Grove Elementary, LA Elementary and Reseda Elementary campuses between 3:30 p.m. and 3:45 p.m. each day. Parents must come to the bus and sign their child/children out. No exceptions.
If a child is picked up during the day and returned, the same sign in and sign out procedure must be followed. No exceptions.
There is no early drop-off or late pick-up.
We have about 450 students that we are teaching, nurturing, and caring for each day. At 3:45 p.m. our staff is ready to take time for themselves and their families. We ask that you respect their time and be on time to pick up your children. Please refer to our Pick-up Policy regarding late pick-up.
Child Pick-up Policy:
In the event that a child is not picked up by 3:45 p.m., and the children have returned to Stanley Mosk, Fullbright, Garden Grove, LA Elementary or Reseda Elementary, the following policy will be implemented.
In the event that the child has to be surrendered to the authorities, Wise Readers to Leaders will not be held liable or responsible for the child after he/she is surrendered to the authorities.
I have read and agree to the above stated policy. I will hold Wise Readers to Leaders harmless and not liable for my child/children if the police have to be called and my child/children surrendered to the authorities.
Wise Readers to Leaders has special field trips planned during our program and would like your permission to take your child.
Authorization for Medical Care: Should it be necessary for my child to have medical care while participating in this trip, I hereby give Wise Readers to Leaders (WRTL) staff permission to use their judgment in obtaining medical care for the child, and I give permission to the nurse selected by WRTL to render medical care deemed necessary and appropriate. I understand that WRTL has no insurance covering such medical or hospital costs incurred by my child and, therefore, any cost incurred for such treatment shall be my sole responsibility.
I hereby certify that the statements in this application are correct and true. I understand that my child’s/children's enrollment as a Wise Readers to Leaders student is based, in part, on the information provided within this application and my agreeing to the terms as outlined in writing by Wise Readers to Leaders.
