Submitted by hawiw@reapusa.org on Thu, 09/01/2022 - 23:28
Student Information
Student Enrollment Fields
Student's Race
Is Student of Hispanic or Latino descent?
Does student have any food allergies?
Is there any student medical information REAP should be aware of?
Does student have a disability that requires accommodations?
Was the student involved in after school activities last year?
Was the student in any leadership positions last year?
Was the student involved in REAP last year?
Is the student involved in the Juvenile Justice System?
Does the student qualify for free or reduced lunch?
Does the student use public transit to and from school?
Does the student receive services from the Oregon Department of Human Services?
Is the student involved in the following organizations? If yes, please select all that apply.
Parent Information
Please read the statement and select one of the following

Release of Information & Publication/Liability


By signing the box below, I understand that I am authorizing REAP employees to have access to my child’s school records in order to perform program services. In addition, I hereby give my consent for any medical treatment or hospitalization that might become necessary for my child and agree to take full financial responsibility for such care.

I hereby fully and forever waive and release REAP, its directors, staff or volunteers from and against any and all claims, demands, losses, liabilities, damages, actions, causes of action, suits, judgments, costs and expenses (including courts or attorney fees) in any way whatsoever arising out of or relating to my child’s participation in REAP.


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Release of Publication Liability Signature


By signing this section of the form, I am authorizing the release for publication of any photos, film or videotape of my child participating in REAP activities. You always have the option for you or your family to opt out of marketing photos and videos published by REAP.


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Virtual Phone Engagement Recording Waiver

As REAP transitions its program offerings to a video chat platform, our organization is taking simple and clear precautions to make sure that all of our interactions remain empowering, constructive, and supportive. 

As a non-profit Community Based Organization (CBO), we value our partnerships with school districts to collaborate and support students in times of crisis. With school-building procedures adapting during this time, REAP wants to maintain our offerings of trauma-informed and restorative based practice, honor the confidentiality of every student, and ensure that student needs are met equitably and responsibly.

As a best practice going forward, the REAP organization will be recording and archiving all virtual interactions from start to finish with this purpose:

1.  REAP will archive all REAP one-on-one, small group, and larger group video chat sessions. This video footage will not be shared outside of the organization without explicit written consent. REAP will only use video footage in case of safety concerns regarding a REAP student or if grievances occur around misconduct from a REAP student or staff.

2.  If given consent through the REAP Enrollment Form, REAP may use brief clips of group and one-on-one engagement for REAP marketing materials. These interaction clips will not reveal any personal information about REAP students or sensitive group discussion, and any student who does not wish to be included will be blurred out or omitted entirely from any video marketing. 

Additionally, we always encourage all REAP students to invite their parents to engage during one-on-ones, especially for younger REAP leaders.

When you sign below, you agree to your student being recorded in photo and video format. REAP will never use recorded media without a student and family’s consent.


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