Enrollment Form Fall 2023 - Summer 2024

Submitted by joshuay@reapusa.org on Thu, 08/10/2023 - 15:25

Select program(s) you are applying to

Which Journey Academy course are you registering for?

Student Information

Student ID

First Name

Last Name

Pronouns

Nickname

Student Profile Picture

One file only.
800 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Birth Date

Gender

Grade

What is the students gender identity?

Country

Street Address

City

State

Zip Code

County

Student Enrollment Fields

Student Personal Email

Students Phone Number

Name of Student's School

Name of Student's School Other

Student's Race

Please list other racial identities

Student of Hispanic or Latino descent?

Language spoken at home

Preferred Language

Does student have any food allergies?

Student's Dietary Restrictions

List food allergies if any

Please provide dietary restrictions

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Medical Information

Does student have a disability that requires accommodations?

Please list accommodation requests

Is there any student medical information REAP should be aware of?

Please list other medical information

Medical Insurance Company

Insurance Policy Number

Parent Email

Names of Attending Family Members

Student T-Shirt Size

Pre-Enrollment Survey

Student's T-Shirt Size

Was the student involved in REAP last year?

Does the student qualify for free or reduced lunch?

What is the parent's total annual household income?

Parent Information

Parent First Name

Parent Last Name

Parent Phone Number

Parent Email

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.

Please sign here

Sign above

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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Date of Signature

Name of Student's School District

Yes

Did you graduate high school this year?

Yes

Are you moving on to the following grade?

Yes

To ensure we provide the best support for your student, please indicate if any of the following apply. This information is confidential and helps us tailor our programs to better meet student needs (Please check all that apply)

To help us better understand the needs of our students, please indicate which range best describes your household's annual income. This information is confidential and will only be used to determine eligibility for certain program benefits/fee reductions