AFTER SCHOOL CONTRACT 2008-2009

LAUSD Grant 2008-2009
S.T.A.R. Inc. [“STAR”] a 501(c)3 non-profit organization
AFTER SCHOOL CONTRACT 2008-2009

CHILD'S NAME: __________________________________________________________ Permit: _________ Grade: ________
Age: ___________ Date of Birth: ____/____/____ Sex: M____ F____ Home Language: _________________________
Home Address: __________________________________________________City: ________________________Zip: ____________
Home Phone#: _____________________________ E-Mail Address: _____________________________________
Parent/Guardian1 Name: _______________________________________________ Cell#: _________________________________
Guardian 1 Employment: _____________________________________________Position: _______________________________
Address: _____________________________________________City: ___________________________ Zip: _________________
Work Phone#: ______________________________ E-Mail Address: _____________________________________
Parent/Guardian2 Name: _______________________________________________Cell#: _________________________________
Guardian 2 Employment: _____________________________________________Position: _______________________________
Address: ______________________________________________City: _________________________ Zip: __________________
Work Phone#: ______________________________ E-Mail Address: _____________________________________
Participation in Program
Students are required to attend the program daily for maximum benefit from core curriculum and enrichment programs. In addition, students are expected to complete the daily rotation of classes everyday. If continued absences become a pattern, the student will be asked to leave the program so that others may benefit in his/her place.

TARDINESS AND PICK UP
Late pick up policy: STAR closes promptly at 6:00 p. m. Repeated tardiness may result in cancellation of your child's enrollment in the program. Excessive tardiness is considered to be more than 3 times in the school year. Late Fee is $1.00 per minute after 6:00 p.m. STAR allows a ten-minute grace period. At 6:11 the late fee is $11.00, 6:12 the fee is $12.00 etc. You must pay the late fee upon arrival. Please pay the staff member(s) in cash only. If you do not pay, your child may not attend the program until that balance has been paid in full. When late, our staff member will make every effort to contact you or persons listed as your emergency contacts. If we are unable to make contact by 7:00 p.m. the school police will be contacted and your child will be taken to the local school police station. Staff is not allowed to take children home.

STAR PHOTOGRAPHY & VIDEO CONSENT
Occasionally STAR will use a student’s photograph and/or film/video for promotional purposes of the organization. Your signature below indicates your permission to allow STAR to use your child’s photograph and or film/video for promotional purposes.

Parent/Guardian Name (Print): ________________________________________

Parent/Guardian Signature: ___________________________________________ Date: ________________

RELEASE OF LIABILITY
I hereby agree to hold harmless STAR, Inc, STAR Staff, Directors, Administrators and Members of the Board of Directors from any liability related to any and all STAR activities and programs. I hereby acknowledge the existence of the implied risk associated with all programs for children and the areas where such activities and programs take place.

I HAVE READ AND UNDERSTOOD ALL THE INFORMATION INCLUDED IN THIS CONTRACT AND BY SIGNING, I AGREE TO ADHERE TO THE TERMS OF THIS CONTRACT. IT IS FURTHER UNDERSTOOD THAT POLICIES AND TERMS OF THIS CONTRACT MAY BE CHANGED AND AMENDED, AND, THAT I SHALL BE INFORMED IN WRITING OF SUCH CHANGES WITH A 30 DAY NOTICE. I HAVE RECEIVED A COPY OF THIS CONTRACT.

Parent/Guardian Name (Print): ________________________________________

Parent/Guardian Signature: ___________________________________________ Date: ________________
(03/08)


Please Indicate Ethnicity (optional)
 American Indian/Alaskan Native Asian Hispanic Black (not of Hispanic origin)
 White (not of Hispanic origin) Filipino Pacific Islander Other_____________________

EMERGENCY CONTACTS
The law requires guardians to sign their child in or to sign them out. Failure to comply with this law may result in suspension or termination of this contract. Your child/children will not be released to any person that is not listed on the emergency contact list. If you need to have your child/children picked up by someone not included in this list, we require both a telephone call from you and a written authorization. Appropriate identification will be required.
By law children must be released to either parent even if one parent is not included on this form. STAR must have a copy of any court document that mandates special custody arrangements. Besides guardians listed above, we will release children only to the following individuals:
Name: ______________________________________________________________ Relation: ________________
Address: ____________________________________________________________ Phone#: _________________
Name: ______________________________________________________________ Relation: ________________
Address: ____________________________________________________________ Phone#: ________________
Name: ______________________________________________________________ Relation: ________________
Address: ____________________________________________________________ Phone#: ________________
Name: _______________________________________________________________ Relation: ________________
Address: _____________________________________________________________ Phone#: ________________
DENTIST'S NAME: ______________________________________________Ph#_________________________
Address: _______________________________________City__________________________________
PHYSICIAN'S NAME: ____________________________________________Ph#_________________________
Address: _______________________________________City__________________________________
EARTHQUAKE OUT OF STATE CONTACT: ___________________________________________PHONE#__________________
List any specific health concerns your child may have (i.e. Illness, allergies, sensitivities, etc):
_____________________________________________________________________________
Does your child have any special needs? (Please specify physical, emotional, dietary or others such as autism, asbergers, tourettes,
ADD, ADHD etc.) _____________________________________________________________
STAR will conduct all of its programs using District facilities in accordance with all federal, state and local regulations and in a manner necessary to provide equal opportunity and access to our programs. The programs offered by STAR vary in programming and rigor among the various campuses. If STAR becomes aware that a child is in need of accommodation or modifications to the STAR program to participate, STAR will consult with the school administrator to determine on a case-by-case basis what reasonable accommodations or modifications, if any, that may be necessary and/or appropriate for each particular program.

EMERGENCIES
In case of an emergency, STAR will make every effort to contact the guardians of the child involved, before any treatment is begun. However, in the event we are unable to make contact with the parents or guardians, we require this medical release to be signed by all the participants in the program.

I HEREBY AUTHORIZE THE PHYSICIAN OR HOSPITAL SELECTED BY THE STAR PROGRAM TO HOSPITALIZE, SECURE TREATMENT FOR, AND TO ORDER INJECTION, ANESTHESIA, OR SURGERY FOR MY CHILD.

It is further understood that the undersigned will assume full responsibility for any such treatment, including the payment of all costs, and will hold STAR Inc., its representatives, the STAR directors, teachers and staff, harmless there from.

Name of Insurance: ____________________________________________ Policy #: ________________
Parent/Guardian's Name (Print): _____________________________________
Guardian’s Signature: _______________________________________________
Date: _______________