1) Student Information Student’s Name:

(Please check the appropriate program.)

Date of Birth: / /

Social Security #:

Race/Ethnicity:

Male Female

Grade Level:

Name of School:

Name of Site:

State

MCT Scores: Reading Language Arts Mathematics

Has this child ever repeated a grade? Yes No

Has this child previously participated in Kids Kollege? Yes No

Does your child have special needs? Yes No

If yes, what is the child’s ruling?

2) Contact Information

Name of registering adult:

Relationship to child: Mother Father Grandmother Guardian Foster Parent

Mother

Name:

Email Address:

Address:

City:

State:

Zip Code:

Cellular Telephone:

Work Telephone:

Home Telephone:

Work Name and Address:

City:

State:

Zip Code:

Father

Name:

Address:

City:

State:

Zip Code:

Cellular Telephone:

Work Telephone:

Home Telephone:

Work Name and Address:

City:

State:

Zip Code:

Household Annual Income: $

Do any of your child (ren) receive free/reduced priced lunch? Yes No

How many people live in your household?

How many children live in your household?

List any other person who is authorized to pick up your child and/or be contacted in an emergency:

3) Liability Release
Field Trip Permission
I authorize my child to accompany Kids Kollege to any on-site or off-site field trip.  Kids Kollege staff will accompany the class.  Detailed information will be sent home prior to any off campus departures.

Photo Release Permission
I hereby give Kids Kollege permission to use any photographs/videotape footage of my child for public relations purposes.

Medical Release
I authorize school personnel to take any medical measures necessary.  Medical emergencies will be taken to the nearest hospital and I understand that I am responsible for all costs incurred.  Kids Kollege will be released from all liability.

Academic Performance Release
I authorize the school to release my child’s Academic Performance Appraisal, progress reports, report cards, IEP, MCT, and records to the Supplemental Education Services (SES) or afterschool provider each nine weeks in order to monitor my child’s progress in the Kids Kollege program.

Liability Release Form
(Release of All Claims)

In consideration for being accepted by Jackson State University for participation in Kids Kollege (program or activity), I do hereby release, forever discharge, and agree to hold harmless the directors, staff, employees, and agents from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above-described program or activity including recreation and work activities.  The undersigned further hereby agrees to hold harmless and indemnify Jackson State University, its directors , staff, employees, and agents for any liability sustained by acts of said participant, including expenses incurred attendant thereto.

Signed this day of , 20

It is understood that Jackson State University does not provide medical insurance covering injury of any nature incurred at the specified program/activity or transportation to or from said program/activity and Jackson State University suggests that my child be covered by medical insurance while participating at the program or in Jackson State University’s facilities.

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or in jury that may require the same.  In the event of the necessity of such care or treatment heretofore described, the undersigned agrees to hold harmless and indemnify Jackson State University, KIDS KOLLEGE (program or activity), its directors, employees and agents from any acts of malfeasance, and or failure to act on the part of those chosen to administer medical care on behalf of the participants.

I, the undersigned, hereby release Jackson State University, its successor, assignees, officers, agent and employees from any and all claims, demands, and causes of action whatsoever in any way growing out of or resulting form my child participating in the program associated with Jackson State University.

Print Participant’s Name:
Parent/Guardian’s Signature:
Participant’s Insurance Company:
Policy Number:

4) Medical Information
Please list any medications taken by the student:

Medication Name:               

Please list any allergies, allergy to medications, chronic illness or other conditions:

List any special accommodations needed for your child’s participation in our program:

If first aid is needed for your child, a classroom teacher or COD staff will administer the treatment.

Permission to Self-Medicate

If medication needs to be taken while in class, please complete this form and return it with the medication in the original pharmacy container to the open Campus Center , Kid Kollege.  Your child will be allowed to self-administer his/her medication under staff supervision at the specified times only with this completed form.

5) Kids Kollege Youth Education
Student Code of Conduct
Youth Education Student Code of Conduct
This form must be returned by:
Classroom Instructor Class Code
The opportunity to study at Kids Kollege at Jackson State University is a privilege and students are accountable for their own conduct. The intense and abbreviated summer schedule warrants the institution of a strict behavior policy. Disciplinary procedures often instituted during the academic school year do not apply to this summer school program. When a student is found to be in violation of the Student Code of Conduct, the Summer School, the Summer School Coordinator and or Assistant Director will access the situation and make an irrevocable decision.
I. The following types of conduct are examples for which police action and removal from the program shall transpire:
A. Possessing, using, distributing, or attempting to use or distribute weapons, illegal or controlled substances or look alike, including drugs, alcoholic beverages and fireworks are prohibited.
B. Intentionally damaging, destroying, attempting to damage or destroy, or theft of college property, or the property of college personnel or other students. Students engaging in such activity shall be liable for any and all costs incurred.
II. The university shall impose police action for violation of smoking ordinances. This applies to persons under the age of 18 on the Kids Kollege Campus at Jackson State University.
III. The following types of conduct are examples that shall result in removal from the program.
A. Assaulting, threatening, harassing, or endangering the health or safety of students, college personnel, or anyone else within college facilities is prohibited.
B. Verbally abusing college personnel or students.
C. Willfully impeding, obstructing, interfering with, or disrupting the performance of the college education function.
D. Failing to cooperate with Public Safety Police personnel in the lawful performance of their duties.
E. Illegal or unauthorized use of computers and the Internet as detailed in the Appropriate Use of Computer/On-Line Resources Contacts.
IV. Cheating, plagiarizing, forgery, or any other form of academic dishonesty shall result in removal from the program.
A. Student caught in any form of cheating will receive and automatic zero on the assignment.  Parents will be notified.
B. A repetition of such an offense shall result in an "F" for the semester grade.
V. In a addition, attendance in the high school summer school program is MANDATORY and students are expected to attend class or be subjected to removal from the program. Refer to Youth Education High School Attendance Policy, which must be signed by all students and parents/guardian.
I, the participant, and I, the parent/guardian, understand and agree to abide by the Kids Kollege Student Code of Conduct. I acknowledge that I am fully aware of the consequences resulting form the violation of any of the guidelines listed above. I understand that disciplinary Coordinator or Asst. Director employed by Kids Kollege shall apply action in a consistent and non-discriminatory manner. Their decisions involving disciplinary measures are binding and will not be overruled by Youth Education of Kids Kollege or Jackson State University administration.
Kids Kollege Code of Conduct Contract
Print Student Name: Print Parent Name