Student Name*
First
Middle
Last
Address*
Birth Date*
Date Format: MM slash DD slash YYYY
Gender*
Student Age (as of August 15, 2020)* Please Select One 5 6 7 8 9 10 11 12 13 14
Grade Entering in Upcoming School Year (2020-2021)* Please Select One Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th
School Attending 2020-2021 School Year (via e-Learning)*
School Zoned For (if different than one attending)
Student Schedule/Computer Information
In order for our staff to assist your student through their school day, please provide the following information:Student Computer Login (06 Number)*
Student Password for Broward Schools*
Student Schedule* Upload a copy of your student's schedule as provided by the teacher
Student Laptop Username and Password*
Canvas Username and Password*
i-ready Username and Password*
Clever Username and Password*
Class Dojo Username and Password*
Other Important Login and Password Information?
Which schedule does your Middle School follow?* Middle School Students Only
Please Select One My school day is a "Straight Schedule" (8:30 am-3:55 pm) My school day is a "Block Schedule" (8:30 am-3:10 pm) I'm unsure which schedule my child's Middle School uses My child is not in middle school
Teacher Name (if known)* If unknown, write "N/A"
Language Fluency* We want to be sure we can assist your child as much as possible in their e-learning environment. Please check below if your student is enrolled in an ESOL (English as a Second Language) Program at their school:
Please Select One Yes, my child is enrolled in an ESOL program No, my child is not enrolled in an ESOL language and they are fluent in English Other
If your child is in an ESOL Program, what is their primary spoken language?
Does your child have a current 504 Plan or Individualized Education Plan (IEP) in Broward Schools?* If yes to above, please upload it here (pdf or jpg)* Medical Information: In order to best care for your child, please list any medical, social, emotional or behavioral concerns we should be aware of. Please list any allergies (food, medicines, insects, etc. and list any medications) A note regarding students with special needs: The Remote Learning Program is an inclusive program. It is imperative to customize our program to meet the diverse needs of all our students, including students with special needs. We know when inclusive practices are incorporated in our program, it enables all students and staff to get the maximum academic, personal, and social benefits from their experience. We recognize that many children need accommodations and modifications to have equitable and genuine opportunities to participate in and learn from the everyday routines, interactions, play and learning experiences that occur in our program. There are many strategies we will put in place for our program to include all students. We will intentionally and meaningfully engage students with special needs in a wide range of learning opportunities, and activities that are available to all children, including participation in the general education curriculum, supplemental activities, and extracurricular activities. Our goal is that all students feel they are respected and belong. Please describe your child’s needs below and a staff member will contact you to discuss the program in more detail to be sure we can meet those needs. We may offer a two week trial to see if the environment is suitable for your student.
Will Your Student Require Any Medication or Insulin and/or Use of an Inhaler?* Please Select One Yes (additional forms will be provided by email) No
How did you find out about JA World Remote Learning Program?* If Other*
Parent/Guardian Information Email Address (Please add JASouthFlorida.org to your approved email list)*
Parent/Guardian Name #1*
First
Last
Primary Cell Phone Number* Please provide a cell phone number. We will use this number to send important text message reminders.
Alternative Phone Number*
Parent/Guardian Name #2
First
Last
Phone Number
Alternative Phone Number
Family Password* Please provide a family password to use when you pick up your child. This password should not be shared with anyone except the individuals listed as Authorized Pickups. Anyone picking up your child will be required to know the password.
Emergency Contact Information/Physician/Authorized Pick-Up Emergency Contact First and Last Name (other than parents)*
First
Last
Relation to Student*
Phone Number*
Student Physician's Name*
First
Last
Student Physician's Phone Number*
Authorized Pick Up Person #1
First
Last
Authorized Pick Up Person #1 (Cell Phone)
Authorized Pick Up Person #2
First
Last
Authorized Pick Up Person #2 (Cell Phone)
Remote Learning Program Sessions SESSION DATES* The Remote Learning Program was created to help families while Broward County Public Schools are offering e-learning. These session dates may be adjusted based on the BCPS’s Reopening Plan. At this time you can register for the second session. Additional Sessions will open as needed thru December. Parents will be immediately notified of any changes and payments will be refunded if the program ends before the scheduled end of the Session.
PICK UP TIME* The Remote Learning Program is a Full Day Program that is open from 7:30 am – 5:30 pm. All students must arrive by 7:45 am, however we understand some families may only need a partial day program. Please check below on the approximate time you will be picking up your child in the afternoon (if this changes in the future, please let the program director know so that we may plan accordingly):
Please select one Approximately 3:30 pm Approximately 4:30 pm By 5:30 pm (Late charges will be assessed the same day for any pick-ups after 5:30 pm) Unsure, times may vary daily/weekly
FEES
$5 - $1,000 per 5-week Session (fee adjusted if registering after session begins)
OPTION 1: FULL PRICE PAYMENT
Check the Sliding Scale Fees, if your household income is above the ranges, your price is $1,000 for the 5 Week Session ($200 per week)
Full Price Payment
Price: $200.00
Enter 1 for Full Payment of First Week ($200)
OPTION 2: SLIDING SCALE PAYMENT
Check the Sliding Scale Fees. Select 1 one of the four options based on number of family members in household and annual income. Please attach the first page of your Tax Return.If Family Members in Household = 2 Household income - Fees Per Child, Week 1 Payment
Please Select One $0 to $24,000 = $5/week $24,001 to $28,000 = $10/week $28,001 to $32,000 = $20/week $32,001 to $36,000 = $30/week $36,001 to $40,000 = $40/week $40,001 to $44,000 = $50/week $44,001 to $48,000 = $60/week $48,001 to $52,000 = $70/week $52,001 to $56,000 = $80/week
If Family Members in Household = 3 Household income - Fees Per Child, Week 1 Payment
Please Select One $0 to $29,000 = $5/week $29,001 to $33,000 = $10/week $33,001 to $37,000 = $20/week $37,001 to $41,000 = $30/week $41,001 to $45,000 = $40/week $45,001 to $49,000 =$50/week $49,001 to $53,000 = $60/week $53,001 to $57,000 = $70/week $57,001 to $61,000 = $80/week
If Family Members in Household = 4 Household income - Fees Per Child, Week 1 Payment
Please Select One $0 to $34,000 = $5/week $34,001 to $38,000 = $10/week $38,001 to $42,000 = $20/week $42,001 to $46,000 = $30/week $46,001 to $50,000 = $40/week $50,001 to $54,000 = $50/week $54,001 to $58,000 = $60/week $58,001 to $62,000 = $70/week $62,000 to $66,000 = $80/week
If Family Members in Household = 5+ Household income - Fees Per Child, Week 1 Payment
Please Select One $0 to $38,000 = $5/week $38,001 to $43,000 = $10/week $43,001 to $47,000 = $20/week $47,001 to $51,000 = $30/week $51,001 to $55,000 = $40/week $55,001 to $59,000 = $50/week $59,001 to $63,000 = $60/week $63,001 to $67,000 = $70/week $67,001 to $71,000 = $80/week
Please upload the first page of your Tax Return* Upload a PDF or JPEG file
Financial Hardship Please upload documentation about your income change (termination letter, etc.)
Please describe your financial hardship here that has caused your household income to change. (loss of job, etc.)
Parent Guardian Agreements
If you have any questions about this agreement, please contact JA at (954) 979-7100 to discuss your concerns.JA SAFETY & OPERATIONS PLAN* Junior Achievement of South Florida and Community After School’s highest priority is the safety of its students, staff and other visitors. JA & CAS wants to ensure parents, guardians and participants that it has a plan in place to protect staff, children, and their families from the spread of COVID-19. This guide includes everyday preventive actions to control the spread of this respiratory illness. Please take a few moments to read to read JA Remote Learning Program Operations and Safety Plan to Prevent the Spread of COVID-19.
STAY HOME IF SICK POLICY* If your student, or anyone in the household, is experiencing any symptoms of covid19, they may not attend the Remote Learning Program. Symptoms include:
• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
FOLLOWING RECOMMENDED COVID-19 GUIDELINES* In order to ensure all students are staying as safe as possible during the COVID-19 pandemic, students and members of their household must follow CDC, Florida Department of Health and Broward County guidelines. As of August 15, these guidelines include:
TEMPERATURE SCREENING* Each student staff member will be screened for symptoms of Covid19 daily. This screening includes a series of questions that parents/guardians will answer daily during drop off, and a morning and mid-day temperate check with an infrared thermometer.
CONTACTS LISTED* The undersigned hereby authorizes officials of Junior Achievement of South Florida and Community After School to directly contact the persons named on this application.
MEDICAL RELEASE* In the event of a medical emergency, Junior Achievement staff will contact emergency medical personnel first and will then contact the child’s parent/guardian or listed emergency contact. Based on medical personnel’s assessment, your child may be transported to a local hospital to receive further medical attention. I hereby release and discharge Junior Achievement Camp, Junior Achievement of South Florida, Inc., Junior Achievement USA, Community After School, Inc. and Broward College, from any and all financial responsibility for the medical care and/or transportation of such child to receive medical care. I agree to indemnify and hold harmless Junior Achievement Camp, Junior Achievement of South Florida, Inc., Junior Achievement USA, Community After School, Inc. and Broward College from any and all claims, damages, costs, attorneys' fees, or damages of any kind arising out of participation in Junior Achievement by the child named above.
PAYMENT - SESSION FEES & LATE DISMISSAL CHARGES* Payment for the Session is due 7 days prior to the Session Start Date.
If Broward County Public Schools reopen during a scheduled 5-week Session, prorated refunds will be issued and/or rates may change if program changes to Hybrid model (students in school only a few days a week).
The hours of JA Remote Learning Program operation are 7:30 am-5:30 pm. This is intended to fully inform you as to our policy regarding student arrivals and dismissal.
Arrival: The building does not open before 7:30 am. Students should arrive for check-in between 7:30 am-7:45 am. It is important for your child to arrive during this time so they have ample time to prepare for their e-learning session with Broward County Public Schools.
Dismissal: Students should be picked up no earlier than 2:30 pm and no later than 5:30PM. If you are late at dismissal, a staff member will be required to stay late and care for your child. A fee of $5.00 per minute past 5:30 pm will be billed, with payment due prior to the next day of the program(cash or credit card only). **You must contact us if you will be late or we may be required by law to contact local police and Child Licensing and Enforcement.
CANCELLATION AGREEMENT* No refunds are available for cancellations after August 26, 2020.
ABSENSES/WITHDRAWLS/NO SHOWS/DISMISSALS* Any absences, withdrawals, no-shows or disciplinary dismissal will not be eligible for refunds, transfers or prorating.
STUDENT BEHAVIOR AGREEMENT* • 1st Offense: Verbal Warning, possible removal from group and discussion with supervisor.
MEDIA RELEASE FORM* I consent for my student to be photographed and/or videotaped in activities or programs of Junior Achievement of South Florida, Inc. and Community After School for our use in communication, marketing, advertising materials or other publication, including social media sites.
MEDICAL FORMS (Students under 6 only)* All students under the age of 6 must submit a physician signed copy of current (within one year of student’s starting date) Certificate of Good Health (HRS Form 3040) and Florida Certificate of Immunization, including a TB test (HRS Form 680) prior to the start of the program. (These forms used to be commonly known as the “yellow and blue forms” for school.) Please remember that students under 6 cannot start the program without his/her health form on file. The signed forms can be uploaded below. Students 6 years old and older do not need any additional forms to register.
If my child is under 6 years old* Please attached a PDF or JPEG file
Waiver of Liability, and Indemnity Agreement
IN CONSIDERATION for being permitted to utilize the services, and programs of Junior Achievement of South Florida (JA). Community After School (CAS) and/or for my children listed above to so participate for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with JA. The undersigned, on behalf of such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as ‘the undersigned”) hereby acknowledges, agrees and represents that he or she has carefully considered such premises, equipment and facilities and/or the affiliated program and that the undersigned finds and accepts same as being safe and reasonably suited for the use or participation by the undersigned and such participating children.
Complete Waiver of Liability, and Indemnity Agreement* I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENT APART FROM THAT BY AGREENING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM JA IN THE CASE OF ILLNESS, INJURY, DEATH OR PROPERTY LOSS OR DAMAGES, INCLUDING , FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AT THE JA FACILITY AND ANY ILLNESS, INJURY OR DEATH RESULTING THEREFROM. I UNDERSTAN THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS. IF SIGNING ON BEHALF OF MINOR: I ALSO UNDERSTAND THAT THIS AGREEMENT IS MADE ON BEHALF OF MY MINOR CHILD(REN) AND/OR LEGAL WARDS AND REPRESENT AND WARRANT TO JA THAT I HAVE FULL AUTHORITY TO SIGN THIS AGREEMENT ON BEHALF OF SUCH MINOR(S).
Total
$0.00
Credit Card* Parent/Guardian Digital Signature*
Today's Date
Date Format: MM slash DD slash YYYY
