For the 2016-2017 school year

Please specify relationship to student

Please make sure Mike@826chi.org and Maria@826chi.org are BOTH in your address book.

Please make sure Mike@826chi.org and Maria@826chi.org are BOTH in your address book.

Please specify relationship to student

Please specify relationship to student

Please list the full name(s) of those who have permission to pick up or drop off your child, including their relationship to the child.

Please check all that apply:

Please list any existing medical conditions or allergies the student has including medication, food, and latex / material allergies. Please indicate the name and dosage of medication, vitamins, or herbal treatments the student is currently taking. Please notify us of any changes so we can follow up accordingly.

I hereby authorize adult workers with 826CHI to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I also give my consent to transportation to a medical facility by ambulance or private vehicle; whichever is necessary in an emergency. Further, as parent or guardian of the named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services. I release 826CHI and 826CHI employees from liability for injury or accident, and do give my permission to secure proper medical attention for above named minor should the need arise. I understand that I will be financially responsible for any expenses incurred due to medical care, travel expenses, etc. due to an accident or illness. I release 826CHI from any financial responsibility that may be incurred due to injury, accident or illness.  

While your child (ren) is engaged in programming at 826CHI, he or she may appear in photographs, video or radio footage that 826CHI may wish to use in its promotional materials (which include the 826CHI fact book and website) or on the radio. These materials help provide the public with information about programs at 826CHI, allow students the opportunity to have their work aired on the radio, and are used to help 826CHI raise money to support the writing center and its programs.  Please note that although permission for use of photographs, video or radio footage of your child is voluntary, once consent is provided by signing this form, it cannot be withdrawn. Also, 826CHI is a nonprofit organization and will not be able to provide monetary compensation. Please check "Yes, I Agree" below to grant permission to use the material. I hereby grant permission to 826CHI to use my child’s photograph, video and/or radio footage without further consideration. I acknowledge the organization’s right to crop, treat or edit, the photograph, radio or video footage at its discretion. I acknowledge that 826CHI may choose not to use the photo or material at this time, but may do so at its own discretion at a later date. I acknowledge 826CHI will not provide monetary compensation for the photographs or material.

We ask your permission to publish and reprint student work. Please select "Yes, I Agree" to the follow: This is an Informed Consent and License Agreement between you, the author ("Author"), and 826 for material to be published in a forthcoming 826CHI Book or in any publication associated with 826CHI or 826 National. The Author understands and consents that although participation in 826CHI is completely voluntary, once consent to publishing the work is provided by signing this form, it cannot be withdrawn.   The Author understands and consents that 826 reserves the right to edit and publish the Author’s work in any manner in the 826 Collection and/or any other publication affiliated with 826CHI or 826 National.  826CHI also reserves the right to paraphrase or re-word passages during the editing process. The Author understands and grants 826CHI the right to publish Author’s work in all editions and version of 826CHI’s Collection or any publication associated with 826CHI or 826 National.   The Author understands and consents that 826CHI and 826 National are non-profit organizations, and will not be able to provide monetary compensation. The Author warrants to 826CHI that he/she is its sole author and that he/she has full power to make this Agreement. If the author is under 18 years of age, his or her parent or guardian must sign below.   I have read the above information, and hereby acknowledge and accept the terms and conditions set forth herein.  

826CHI is a creative writing and tutoring center, where students may come to work on and receive assistance with school or writing. Although students are encouraged to feel at home while in the center, they are also expected to be focused and to be respectful of their surroundings. We reserve the right to ask students we feel are being too disruptive to leave. Please understand that 826CHI is a tutoring center and should not be considered an alternative to day care or babysitting services. Parents are responsible for making any necessary arrangements for getting their child home immediately after programming ends. Select "Yes, I Acknowledge" if you have read and understood this statement.

Please acknowledge our 826CHI statement regarding priority enrollment and check "Yes, I Agree:" Priority Enrollment Statement:  Priority enrollment for Workshops will be reserved for students who live in the City of Chicago and are from low-income families and/or English Language Learners. We ask that parents who enroll their children in the Workshops self-identify as low-income and/or have children who are ELL's.

If so, please describe your experience and what you're looking forward to this time!

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