Super Summer 2020 Survey

1.What is your students' first name?(Required.)

2.What is your students' last name?(Required.)

3.What is your child's date of birth? (MM/DD/YYYY)(Required.)

4.What school does your student attend?(Required.)

Walt Whitman

McClure

Other (please specify)

6.What is your student's T-shirt size (youth sizes)?(Required.)

7.Guardian First Name(Required.)

8.Guardian Last Name(Required.)

9.Guardian Email(Required.)

10.Guardian Phone Number(Required.)

11.What is your Summer address?(Required.)

12.Do you have more than one student who will participate in Super Summer?(Required.)

Yes

13.Does your student have access to the internet and technology? (laptop, desktop, Chromebook, etc.)(Required.)

Yes

If no, please detail your child's' technology needs.

14.What is your student's TPS Meal ID Number?

15.Does your child have any known allergies(Required.)

Yes

If yes, please detail the allergies and note any known things that trigger the allergy:

16.I understand that The Opportunity Project "Super Summer" is asking to share information about my child, collected by program staff, with appropriate school faculty and Tulsa Public Schools, and I grant permission to The Opportunity Project "Super Summer" to share information about my child with Tulsa Public Schools and for Tulsa Public Schools to share information with The Opportunity Project "Super Summer".(Required.)

Yes

17.I hereby agree and consent that The Opportunity Project "Super Summer" and its partners may publish, broadcast and/or copyright for all purposes, my child’s statements and/or pictures taken of my child and/or my property for advertising and public relations purposes, and I waive all claims for compensation for such use.(Required.)

Yes

18.I understand to improve The Opportunity Project "Super Summer", surveys might be conducted of my child or our family. I understand that The Opportunity Project "Super Summer" might also conduct outcome measurement surveys and program evaluations that will be used to improve and to evaluate the The Opportunity Project "Super Summer"program. I understand that my child may complete some surveys online.(Required.)

Yes

19.(REQUIRED FOR CHILD(REN) TO PARTICIPATE- PLEASE CLICK THE CHECKBOX AFTER READING) I, the undersigned, hereby understand, acknowledge, and agree that:(Required.)

I have read and understood the foregoing information. Participation by my child in the Super Summer Program and providing information about my child may involve certain risks. By allowing my child to participate in the Program and consenting to provide information as described herein, I am assuming all these risks, including (but not limited to) any physical risks or risk of injury that may be associated with the nature of the Program. All Program providers are responsible for the operation of the Program and the supervision of the personnel associated with their individual programs or handling my child's information. The Opportunity Project and its partners take no responsibility for any occurrence relating to or arising out of these programs operated by the individual providers or the use or receipt of my child's information. In accordance with state law, I hereby waive any liability that The Opportunity Project, Super Summer site management agencies, program providers, and any of their officers, directors, trustees, agents, servants, or employees might have for, and agree that they shall not be liable for any bodily injury to my child incurred while he/she is practicing for, or participating in, any contest or exhibition of an athletic, or sports nature Super Summer-sponsored activity, I hereby assume the risk of any bodily injury incurred by my child while practicing for or participating in any of these activities. Further, I agree that I will not seek to hold The Opportunity Project, nor its partners are responsible for any losses or damages which I or my child may incur in connection therewith, including any mistakes, negligence, omissions, or acts whatsoever of any party in connection with the Program. I understand that my records are protected under the Federal Confidentiality Regulations (42CFR Part 2), Mental Health Law (40.1-2- 26) and Health Care Information Act (RI General Laws 5.37.3-4), and cannot be disclosed without my written consent except as otherwise specifically provided by law. Any information released or received as a result of this consent shall not be relayed in any way to another person, organization, or entity, without additional written consent from me unless it is by the Executive Director of The Opportunity Project acting on my behalf. I understand that state law mandates reporting of suspected abuse/neglect (to children, elderly and disabled persons) to the appropriate State authorities. I may withdraw this consent by giving written notification to the above party, at any time prior to the disclosure or release of the information. I understand and consent to my child's case file, and the record is reviewed and information is used for administrative case review and program evaluation. I have read (or had it read to me), understand, and agree to the conditions as outlined in this release.

20.By typing my full name and date below, I confirm I have read the above acknowledgments and hereby consent to The Opportunity Project “Super Summer” the use of my electronic signature. I understand that my electronic signature on this/these document(s) may not be invalidated solely on the basis that the signature is electronically obtained.
**Please type full name and date(Required.)

Current Progress,

0 of 58 answered

Super Summer 2020

Super Summer Registration