pinellas sheriff's police athletic league big pal after ... pa… · pinellas sheriff's...

Pinellas Sheriff's Police Athletic League Big PAL After-School Program Registration Form

3755 46th Ave. N. - St Petersburg, FL 33714 - Phone: 727-521-5315 Note: This application must be completed in its entirety and signed for your child to attend this program.

Household Information:

Household Last Name: _ # of Adults _ # of Children _

Address: _ Street address (number, apartment #, street)

Housing Situation: (Check one) DRent DOwn DOther

Household Arrangement: (Check one) Douai Parent - Married DOual Parent - Non-married Female head of household DOual Parent - Non-married Male head

City State Zip Code

Do you receive TANF/cash assistance? DYes DNo

of household

DSingle Parent - Female head of household DSingle Parent - Male head of household DOther Relative/Kinship Care - Married DOther - Non-relative

DOther - Relative/Kinship Care - Male head of household DOther - Relative/Kinship Care - Female head of household

Household Income: (Check one) 0$0-$9,999 0$10,000-$19,999 0$20,000-$29,999 0$30,000-$39,999 0$40,000-$49,999 0$50,000 and up

How did you hear about this program? _ HomePhone#: _

Emergency Contact (if custodial parent/guardian cannot be reached):

Name: _ Relationship: _ First MI Last

Address: ------------------ Street address (number, apartment #, street) City State Zip Code

Home Telephone ( ) __ - Cell Phone ( ) __ - Work Telephone ( __ ) __ - _

Approved Adults: Any adult (18 years old or older), other than parent/guardian, listed on this form has your permission to remove your child from our care, and might be called if needed.

Name: Relationship to Child Phone # ( __ ) __ - _




Have you liked us on Facebook? DYes DNo Have you received a Parent Handbook? DYes DNo

Child 1 Information:

Child's Legal Name _ First Middle Last Nickname

Relationship to Head of Household: _ 55#: _ Pinellas Student 10: ------

o Female 0 Male Birth Date__! __!__ Current Grade (as of 8/2015) Child's School: --------

Portal Information: Username: Password: _

Child's Address: _ (If different from Head of Household)

Street address (number, apartment #, street) City State Zip Code

Is the participant a Foster Child? DYes DNo Is teen participant a Pregnant? DYes DNo

Race: (Check one) DWhite DAmerican Indian or Alaska Native DAsian Indian

DAsian Unspecified DOther Asian DBlack African American

Ethnicity: (Check one) DNo, Not Spanish/Hispanic/Latin

DChinese DFilipino DJapanese DKorean

DYes, Puerto Rican

DGuamanian or Chamorro DMulti Racial DOther Pacific Islander

DYes, Cuban

Dsamoan DVietnamese Dsome other Race

DYes, Other Spanish/Hispanic/Latin

Transportation Options (PAL doesn't allow students to come and go, once they sign out they sign out for the day):

Note: PAL is not responsible for your child once they leave PAL programs or property.

Getting to PAL: o PAL will pick my child up at school and transport them to

PAL. o My child will get to the PAL facility on their own.

Leaving PAL: o My child will stay there until I or a previously approved

adult picks my child up. o My child will stay until P.M. then my child will

sign themselves out for the day and get themselves home.

Food Permission: Please check the following: o My child DOES NOT have food allergy or dietary restriction. o My child DOES have a food allergy or dietary restriction. He or she may participate, but may not eat or handle the following items: ___

o My child DOES have a food allergy or dietary restriction. He or she may not participate in activities

Child 2 Information:

Child's Legal Name ___ Nickname First Middle

Relationship to Head of Household: SS#: _

Last

o Female 0 Male Birth Date__} __}__ Current Grade (as of 8/2015) Child's School: _

Pinellas Student ID: _

Portal Information: Username: Password: _

Child's Address: _ (If different from Head of Household)

Street address (number, apartment #, street)

Is the participant a Foster Child? DYes DNa



Ethnicity: (Check one) DNa, Not Spanish/Hispanic/Latin


DYes, Puerto Rican

City

Is teen participant a Pregnant?


DYes, Cuban

State Zip Code

DYes DNo

Dsamoan DVietnamese DSome other Race


Transportation Options (PAL doesn't allow students to come and go, once they sign out they sign out for the day): Note: PAL is not responsible for your child once they leave PAL programs or property.

Getting to PAL: o PAL will pick my child up at school and transport them to

PAL. o My child will get to the PAL facility on their own.

Leaving PAL: o My child will stay there until I or a previously approved adult

picks my child up. o My child will stay until P.M. then my child will sign

themselves out for the day and get themselves home.

Food Permission: Please check the following: D My child DOES NOT have food allergy or dietary restriction. D My child DOES have a food allergy or dietary restriction. He or she may participate, but may not eat or handle the following items: __

D My child DOES have a food allergy or dietary restriction. He or she may not participate in activities

Parent/Guardian 1 Information: Legal Name __ Birth Date_/_/ __

First Middle

Relationship to Head of Household: _





Is parent/guardian Pregnant? DYes DNo

DYes, Puerto Rican

Last

55#: _


DYes, Cuban

o Female 0 Male



Email: _

Parent/Guardian Add ress: _ (If different from Street address (number, apartment #, street) Head of Household)

Cell phone #: __

City State Zip Code

Work #: _ Highest level of education? _

Parent/Guardian 2 Information: Legal Name __

First Middle

Relationship to Head of Household: _





Is parent/guardian Pregnant? DYes DNo

DYes, Puerto Rican

Last Birth Date_/ _/ __

55#: _ o Female D Male


DYes, Cuban



Email: _

Parent/Guardian Address: _ (If different from Street address (number, apartment #, street) Head of Household)

Cell phone #: _

State City Zip Code

Work #: _ Highest level of education? _

PAL Member Expectations: Below are the Lealman Sports Complex PAL Member Expectations. Please go over these with your child.

1. All PAL participants must SIGN-IN when you arrive and SIGN-OUT when you leave (NO coming and going!) Your parents, your school, and PAL expect you to stay inside the PAL complex and have fun.

2. Respect yourself, others, PAL Staff, and PAL equipment by displaying good behavior and manners: profanity, fighting, arguing, raising your voice, stealing, bullying, carrying weapons, or destroying property is not good behavior.

3. Food is available every day; we eat in the game room, breezeway, or classroom portable. We clean up after ourselves and throw trash away and recycle.

4. You are responsible for your belongings. Money, electronics, bikes, etc. are your responsibility. 5. The Dress Code is the same as school; can you wear it to school? Then you can wear it to PAL. Tennis shoes must be worn to play

sports. 6. Academics are important. Every PAL participant goes to the portable on their school days. You, your school, and your parents signed

up for this. 7. Every PAL participant is expected to participate in all PAL activities.

Inability of the participant to conform to the established expectations will result in the notification to the parent/guardian. Pinellas Sheriffs PAL reserves the right to dismiss any participant.

Hold Harmless Agreement: In consideration for PCSO PAL permitting my child to participate in this program, I release the Pinellas County Sheriff's Police Athletic League, and the Pinellas County Sheriff's Office, deputies, members, employees, activity coordinators, and any volunteer specifically authorized by PCSO to supervise PAL activities from all rights, claims and damages for the negligent actions of any PCSO member arising out of this participation. In signing this document I understand that I am releasing or giving up certain potential legal rights and I further acknowledge that I have been advised that I may wish to seek the advice of legal counsel prior to signing this document. Being so informed, I knowingly and voluntarily execute this release and waiver as evidenced by my signature on the last page of this agreement.

Emergencies: In case of an emergency involving my child, I understand every effort will be made to contact the child's parent(s) or legal guardian. In the event they cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child, until such time as I can be contacted .. Also until such time as I can be contacted, I give my permission for medical providers to disclose to the adult in charge the information needed to make an informed decision, including but not limited to disclosing the results of any examination findings, test results, and/or treatment.

Lost/Stolen Items: If your child brings cell phones, electronic devices, or anything of value, they are responsible for them while they are here on Pinellas Sheriff's Police Athletic League property or on any field trips. If the item or items become missing, it is your child's responsibility. We are not responsible for your child's valuables.

Parent/Guardian Initials: I understand that Pinellas Sheriff's Police Athletic League is not responsible for any lost or stolen items including cell phones and any other electronic devices.

Parental Acknowledgement:

I, the parent/guardian, have read and gone over the Expectations with my child and my child and I understand them completely.

I give permission for PAL to transport my child to activities that are off PAL property.

I give permission for my child to watch PG-13 movies.

I give permission for PAL to take/use any photograph or video of my child to help publicize our programs, which may include newspaper, brochures, the year-round tabloid, displays and/or any other forms of publicity for the Pinellas Sheriff's PAL.

By signing this document, I acknowledge that I fully understand the terms of the agreement.

Signature of Parent or Guardian _ Date _

Printed Name of Parent or Guardian ----------------------

FOR OFFICE USE ONLY Enrollment Date _ InGEMSD

-jwb ~ Juvenile Welfare Board

Investing in children. Strengthening our community,

Authorization and Consent for Disclosure, Receipt, and Use of Confidential Information

by the Juvenile Welfare Board of Pinellas County

Participant Name: Participant Phone: _

Participant DOB: Name of Program or Service _

Participant Address: _

I, (print participant name) acknowledge that I am a participant of (name of program or service). I acknowledge that the Juvenile Welfare Board of Pinellas County ("JWB") provides funds to make the program or service in which I am partiCipating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services.

By Signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system, and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. §119.071). I acknowledge that JWB may review all information about me as it specifically relates to any program or service it pays for. I also acknowledge that because JWB provides funds for the program or service in which I am participating, it may review my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB provides no direct services to me, including, but not limited to, coordination of services, recommendation of services, or medical diagnoses. I further acknowledge that JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act).

I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes of funded programs and services, and determination of future services/programs funded by JWB. I understand that the confidentiality of any information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of participants, where no one is identified by name or any other personal characteristic.-

I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/ psychologicall substance abuse information from my medical health record, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459,381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I authorize the release of any information concerning the performance of any tests, results of those tests, counseling and treatment records. I consent to my minor partidpating in online or paper surveys that

-jwb \.:. Juvenile Welfare Board

Investing in children. Strengthening our community

will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization. I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a whole in de-identified format, which means that no information that identifies me as an individual is revealed.

I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program. I understand and agree that if I withdraw my approval that it will not apply to any information already released to and used by JWB as a result of this Authorization.

Specify Above the Date, Event or Condition for Termination of Authorization

By my signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below. ________________________ (print participant name)

Effective Date Signature of Participant or Participant's Authorized Representative (check one): o Participant o Parent o Guardian o Personal Representative (Legal Documents Required)

Description of authority if signed by partiCipant's authorized representative

Witness Signature Date


Investing in children. Strengthening our community.

Authorization and Consent for Disclosure, Receipt, and Use of Confidential Information

by the Juvenile Welfare Board of Pinellas County

Participant Name: Participant Phone: _

Participant DOB: Name of Program or Service _

Participant Address: _

I, (print participant name) acknowledge that I am a participant of (name of program or service). I acknowledge that the Juvenile Welfare Board of Pinellas County ("JWB") provides funds to make the program or service in which I am participating available. I also acknowledge that in order to make sure that all services delivered to participants are of the highest possible quality, JWB may need to review information about me and these services.

By Signing this Authorization, I am indicating that I understand and agree that my confidential information may be contained in a JWB data collection system, and that this data collection system is exempt from disclosure under the Florida Public Records Act. This means that by law, JWB cannot release individually identifiable information about me or the services I receive (Fla. Stat. §119.071). I acknowledge that JWB may review all information about me as it specifically relates to any program or service it pays for. I also acknowledge that because JWB provides funds for the program or service in which I am participating, it may review my participant file and all other information pertaining to me held by the agency providing the program or service, regardless of whether that information is entered into a JWB data collection system. I further acknowledge that JWB is simply storing and reviewing records and information as the payor for these services, and that JWB provides no direct services to me, including, but not limited to, coordination of services, recommendation of services, or medical diagnoses. I further acknowledge that JWB is not a covered entity as that term is defined under HIPAA (the Health Insurance Portability and Accountability Act).

I authorize JWB to utilize my confidential information to verify eligibility for funded services or programs, make payment for services rendered to me by funded programs or services, quality control of funded services or programs, evidence-based research of JWB funded services or programs, including, but not limited to, tracking outcomes offunded programs and services, and determination of future services/programs funded by JWB. I understand that the confidentiality of any information disclosed, received or used by JWB related to my Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law unless it is presented in a report that presents information on a group of participants, where no one is identified by name or any other personal characteristic.-

I acknowledge that this Authorization covers all information about me including, but not limited to, personally identifiable information, Protected Health Information, general medical, general counseling, as well as psychiatric/ psychological! substance abuse information from my medical health record, as allowed by all state, federal and local laws, including, but not limited to the following: Florida Statutes 394.459,381.004, and 395.3025; Florida Evidence Code 90.503, 90.5035, and 90.5036; HIPAA, and the Code of Federal Regulations (CFR) Title 42. I authorize the release of any information concerning the performance of any tests, results of those tests, counseling and treatment records. I consent to my minor participating in online or paper surveys that


Investing In children. Strengthening our community

will be used for program improvements and enhancements. I understand that my records have a privileged and confidential status. I am waiving that status for the purposes contained by this Authorization. I understand that the confidential information disclosed, received or used by JWB based on this Authorization will not be further disclosed to any other party without my express written consent or as otherwise permitted or required by applicable law. However, the individually identifiable confidential information received by JWB based on this Authorization may be used by JWB and its agents for research purposes, so long as the research results are reported as a wttole in de-identified format, which means that no information that identifies me as an individual is revealed.

I understand that I have the right to withdraw my approval in writing at any time. However, it is possible that JWB may have already relied on this Authorization before it receives notice of my withdrawal and that JWB may have already taken action based on the Authorization. If I do not withdraw my approval, it will automatically end one (1) year from the last day I received services from this program. I understand and agree that if I withdraw my approval that it will not apply to any information already released to and used by JWB as a result of this Authorization.

Specify Above the Date, Event or Condition for Termination of Authorization

By my Signature below, I acknowledge that I have given my consent as indicated above freely, voluntarily, and without coercion, and that I have been given a copy of this authorization, signed by me on the date shown below. _________________________________________________ ~rintparl~~antname)

Signature of Participant or Participant's Authorized Representative (check one): o Parlicipant o Parent o Guardian o Personal Representative (Legal Documents Required)

Effective Date

Description of authority if signed by partiCipant's authorized representative

Witness Signature Date

-jwb \.::, Juvenile Welfare Board


Juvenile Welfare Board of Pinellas County 14155 58th Street North, Suite 100

Clearwater, FL 33760 Phone: 727-453-5600

Fax: 727-453-5610 www.jwbpinellas.org

Written Statemept of Purpose(s) for Collection of Social Security Number for Recipients of JWB-funded Programs and Services

The Juvenile Welfare Board (JWB) invests in partnerships, innovation and advocacy to strengthen Pinellas County children and families. The vision of the Juvenile Welfare Board is that children in Pinellas County will have a future of more successful and satisfying lives because of the efforts of JWB and its partners. JWB was established by Florida statute in 1945 (Special Act 2003-320: F .S. § 189.429) and approved overwhelmingly by voters in a referendum in 1946. JWB was created with a mission to provide needed services to children throughout Pinellas County. JWB provides funds to agencies that provide services to children and families in Pinellas County.

The purpose of this document is to provide individuals with written information about how JWB uses the Social Security numbers it collects. JWB is required by Florida's Public Records law [Fla. Stat. § 119.071(5)] to provide this information to you.

Florida law allows JWB to collect Social Security numbers in order to carry out its duties and responsibilities (Fla. Stat. §119.071(5) (a) 2a. (Il); Special Act 2003-320: F.S. §189.429). Specifically, it is necessary for JWB to collect Social Security numbers to conduct research, fund services, and to ensure that all services delivered to participants are of the highest possible quality.

In addition, collecting Social Security information is necessary to:

• Identify and match individuals and data to research and improve how services are provided to children and families; and

• Receive reimbursement from Medicaid, if applicable, for providing services.

By law, JWB cannot release Social Security numbers (Fla. Stat. § 119.071). JWB follows the highest security standards. All reports produced by JWB provide information about services in general. No individual person is ever identified in any way in any report.

Print Participant Name

Participant Signature Date

Print Parent/Guardian Name (if participant is under 18)

Parent/Guardian Signature (if participant is under 18) Date

Statement of Purpose for Collection of Social Security Number2014.02.20.docx

EMERGENCY MEDICAL RELEASE

This form must contain only one child's name, and be the original notarized form.

A new notarized form is required when there is a change in legal guardianship.

Please Print Information

Child's Full Name: _ Blrthdate: _

Aile rg les: _

Medicines Routinely Taken: _

Name of Custodial Parent(s)/Legal Guardian(s): _

Address: _ City State Zip Code Street Address (number, apartment #, street)

Home Telephone Cell Telephone Work Telephone _

Family Physician's Name/Health Care Resource: _

Address: _ Street Address (number, apartment #, street) City State Zip Code

Telephone (_-'-- _

Hospital Preference:_...,.,.. ....".,. _ Name City

Medical Insurance Company: _

Policy #: _ Expiration Date: _

Emergency Contact (if custodial parent/guardian cannot be reached): _

Address: _ City, State, Zip Code Street Address (number, apartment #, street)


Sign in the presence of the Notary.

I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child

_______________________ , in the event of an emergency at which time (Child's Full Name)

I cannot be reached. I give consent to transport by ambulance if situation warrants it.

Signature of Custodial Parent/Legal Guardian (Affiant)

STATE OF FLORIDA COUNTY OF ------------ The foregoing instrument was acknowledged before me on 20, _

(Month) (Day) (Year) by , who is personally known to me or who has

SEAL OF NOTARY (Name of Affiant) produced as identification.

(Type of Identification)

Signed: (Signature of Notary) FC-0003 Sample (7/30/13)

-jwb \.:, Juvenile Welfare Board


Juvenile Welfare Board of Pinellas County 14155 58th Street North, Suite 100

Clearwater, FL 33760 Phone: 727-453-5600

Fax: 727-453-5610 www.iwbpinellas.org

Written Statement of Purpose(s) for Collection of Social Security Number for Recipients of JWB-funded Proerams and Services

The Juvenile Welfare Board (JWB) invests in partnerships, innovation and advocacy to strengthen Pinellas County children and families. The vision of the Juvenile Welfare Board is that children in Pinellas County will have a future of more successful and satisfying lives because of the efforts of JWB and its partners. JWB was established by Florida statute in 1945 (Special Act 2003-320: F.S. § 189.429) and approved overwhelmingly by voters in a referendum in 1946. JWB was created with a mission to provide needed services to children throughout Pinellas County. JWB provides funds to agencies that provide services to children and families in Pinellas County.

The purpose of this document is to provide individuals with written information about how JWB uses the Social Security numbers it collects. JWB is required by Florida's Public Records law [Fla. Stat. § 119.071(5)] to provide this information to you.

Florida law allows JWB to collect Social Security numbers in order to carry out its duties and responsibilities (Fla. Stat. §119.071(5) (a) 2a. (Il); Special Act 2003-320: F.S. §189.429). Specifically, it is necessary for JWB to collect Social Security numbers to conduct research, fund services, and to ensure that all services delivered to participants are of the highest possible quality.

In addition, collecting Social Security information is necessary to:

• Identify and match individuals and data to research and improve how services are provided to children and families; and

• Receive reimbursement from Medicaid, if applicable, for providing services.

By law, JWB cannot release Social Security numbers (Fla. Stat. § 119.071). JWB follows the highest security standards. All reports produced by JWB provide information about services in general. No individual person is ever identified in any way in any report.

Print Participant Name

Participant Signature Date

Print Parent/Guardian Name (if participant is under 18)

Parent/Guardian Signature (if participant is under 18) Date

Statement of Purpose for Collection of Social Security Number2014.02.20.docx

EMERGENCY MEDICAL RELEASE

This form must contain only one child's name, and be the original notarized form.

A new notarized form is required when there is a change in legal guardianship.

Please Print Information

Child's Full Name: _ Birthdate: _

Allergies: _

Medicines Routinely Taken: _ Name of Custodial Parent(s)/Legal Guardian(s): _

Address: _ City Street Address (number, apartment #, street) State Zip Code


Family Physician's Name/Health Care Resource: _

Address: _ Street Address (number, apartment #, street) City State Zip Code

Telephone (_-'-- _

Hospital Preference: _ City Name

Medical Insurance Company: _

Policy#: _ Expiration Date: _

Emergency Contact (if custodial parenUguardian cannot be reached): _

Address: _ City, State, Street Address (number, apartment #, street) Zip Code


Sign in the presence of the Notary. I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child _______________________ , in the event of an emergency at which time

(Child's Full Name) I cannot be reached. I give consent to transport by ambulance if situation warrants it.

Signature of Custodial Parent/Legal Guardian (Affiant) STATE OF FLORIDA COUNTY OF _ The foregoing instrument was acknowledged before me on 20 _

(Month) (Day) (Year) by , who is personally known to me or who has

SEAL OF NOTARY (Name of Affiant) produced as identification.

(Type of Identification)

Signed: (Signature of Notary) FC-0003 Sample (7/30/13)