Beyond the Bell Enrollment
Beyond the Bell (previously known as Teen REACH) is a new after-school program for 5th grade through 17 year olds in Clay County. The program will be located at the old Washington School in Flora (444 S. Locust).

Beyond the Bell will open on November 28th and will be open Monday through Friday from 3:00 p.m. – 6:00 p.m. On early release days from school, the program will start earlier. It will also be open for full days (8:30 a.m. – 4:30 p.m.) on school non-attendance days.

Beyond the Bell will be staffed with professionals and volunteers to run a variety of activities including outdoor activities, sports, crafts and art projects, community service opportunities, homework help and more! The program is FREE and transportation after school is provided from all schools in Clay County. A snack will be provided after school, but not full meals at this time.

Filling out this enrollment form is required for attendance. Enrolling in the program does not mean that the student must come every day. Once the enrollment form is on file, the student is free to attend as many or as few days as they would like.

More information can be found on our website: www.healthdept.org

General Information
Child's Full Name *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Grade *
School *
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number 1: *
Your answer
Parent/Guardian Phone Number 2:
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number 2: *
Your answer
Parent/Guardian Email Address *
Your answer
Preferred Method of Communication *
Anticipated Attendance: *
On what days do you expect your child to attend?
Required
Photo Release
As the legal parent/guardian of the above named child, I authorize the Illinois Department of Human Services and the local Teen R.E.A.C.H. program operators to photograph my child for means of publication purposes. Photos might be used in various brochures and publications describing and promoting the program in a positive way. In no way will the photos be used in any illegal misrepresentation of my child.
By entering your name below you consent to the above photo release *
Required
Electronic Signature *
Parent/Guardian First and Last Name
Your answer
Field Trips
I will allow my child to go on field trips with the Teen R.E.A.C.H. program and its staff. I understand that the Teen R.E.A.C.H. program may provide field trips throughout the course of my child’s participation. My child and I fully understand that all Teen R.E.A.C.H. rules apply, even on trips. I also understand that all field trips will also have another, more detailed, permission slip, providing information concerning the exact logistics of each trip.
By entering you name below you consent to your child participating on field trips *
Required
Electronic Signature *
Parent/Guardian First and Last Name
Your answer
Outcome Measurement Consent
I give permission to the Illinois Department of Human Services and its designees to collect and record data on my child, this data gathering may include, but is not restricted to the following:Surveys and/or interviews about his/her knowledge, attitudes, skills and behaviors in regards to risk-taking behaviors and habits, education and educational resources, positive relationships, career choices, connections to community, and overall satisfaction with the Teen R.E.A.C.H. program. Academic and school department data from report cards and other school reports. These will be collected twice per school year.

I understand that the purpose of these surveys and interviews is to document the impact of the Teen R.E.A.C.H. program on its participants, and to identify areas for improvement. I also understand that this information will remain private, and that only my child’s site director and assigned research assistants will be able to look at his/her responses.
I understand that my child’s responses will be automatically grouped together with the responses of other Teen R.E.A.C.H. sites for any public presentations of their finding, and that my child will not be individually linked to his/her responses. In addition, I understand that I can take back my permission at any time, and that my permission automatically stops when the child leaves the Teen R.E.A.C.H. program.

By entering your name below you consent to the Teen REACH program collective outcome measures for your child *
Required
Electronic Signature *
Parent/Guardian First and Last Name
Your answer
Emergency Contact Information
Please fill out the following information for 3 emergency contacts
Emergency Contact #1 First and Last Name *
Your answer
Emergency Contact #1 Relationship to Youth *
Your answer
Emergency Contact # 1 Phone Number - Primary *
Your answer
Emergency Contact # 1 Phone Number - Secondary
Your answer
Emergency Contact #2 First and Last Name *
Your answer
Emergency Contact #2 Relationship to Youth *
Your answer
Emergency Contact #2 Phone Number - Primary *
Your answer
Emergency Contact #2 Phone Number - Secondary
Your answer
Emergency Contact #3 First and Last Name *
Your answer
Emergency Contact #3 Relationship to Youth *
Your answer
Emergency Contact #3 Phone Number - Primary *
Your answer
Emergency Contact #3 Phone Number - Secondary
Your answer
Emergency Medical
Does youth have Asthma *
Please list youth's prescribed medications *
Your answer
Do medications need to be administered by an adult? *
Please list youth's allergies *
Your answer
Has the youth had any head injuries? *
Your answer
Any other health issues? *
Your answer
Does your child require any restrictions on his/her physical activity? *
Your answer
Any additional medical information of which we should be aware? *
Your answer
Medical Emergency
In the event of a medical emergency, I authorize Clay County Health Department staff to contact one of the emergency contacts listed above and to take whatever actions seem prudent for prompt care and treatment of my child named above. Furthermore, I understand that any medical bills incurred by an accident are my responsibility and I will not attempt to hold Clay County, the Clay County Health Department, or any employees or board members liable for such occurrences. I also understand that 745 ILCS 10/3 Local Governmental and Governmental Employees Tort Immunity Act and related sections in the state statutes provide public entities and employees immunity from liability unless such local entity or public employee is guilty of willful and wanton conduct proximately causing such injury.
By entering your name below you consent to the program contacting one of the above emergency contacts and taking action for prompt care and treatment of child in a medical emergency *
Required
Electronic Signature *
Parent/Guardian First and Last Name
Your answer
ECornerstone Informed Consent
Welcome to eCornerstone, a system that collects and uses data on a wide range of stage programs for individuals. These programs include WIC (Women, Infants and Children; Immunizations; Case Management; Prenatal and Postpartum Care; Pediatric Primary Care; Early Intervention; Breast and Cervical Cancer; Diabetes Control; Youth Programs; Health Families Illinois; and Teen REACH.)

We are seeking your permission to share information about the participant of enrollment and case-management purposes. This information includes the participant’s participation in any of the programs listed above. Based on the information, we may determine that the participant could benefit from other state-funded programs. We will also use the information in order to provide and pay for services for which the participant is enrolling, and to refer the participant for other necessary services.

We protect personal information we collect about the participant by maintaining physical, electronic and procedural safeguards. Program participation information will be shared only with authorized staff with a direct need to know about the participant. Information may also be released as necessary for participation authorization, and for programs audit and evaluation purposes. Necessary information, without any participant’s name, will also be sent to Federal and/or State agencies that fund the program.

By signing this Consent form, you agree to allow the information as described in the Consent to be used by this agency/clinic as described in the Consent. The person(s) receiving this information has(ve) a legal and ethical duty to keep the information confidential and private and not release it to anyone else except as described in the Consent, without your written permission, unless the law allows it.

I hereby authorize Clay County Health Department (eCornerstone site) to compare data already entered in the computer system regarding any other of the above programs that the participant my have participated in, with data about the participant collected during this enrollment/registration process, and to release data as necessary to provide the service requested and the referrals necessary.

This consent covers all the medical, social and financial information about the participant, including participant background and demographic information; health visit information; medical and developmental history; prenatal birth, and postpartum data; infant/child visit data; immunization records; participant risk and protective factors; problems or factors that prevent the participant from receiving proper medical care; appointments made and services received; goals and care plan; WIC food packages; program information; information required by the federal Maternal and Child Health Block Grant Program; Youth Programs; and Early Intervention Program, but only as relevant to the service being provided and as necessary to accomplish the above purposes.

This consent does not cover information about the diagnosis of treatment for mental health, AIDS, HIV, sexually transmittable diseases, alcoholism, and drug abuse which will not be released to other programs pursuant to this consent.

I am making this consent within the limits of my legal authority. I understand that I may revoke this consent in writing at any time, but that revoking this consent will not cancel what was done before I revoked it. I also understand and agree not to hold this agency or the Illinois Department of Human Services or Public Health liable for the release of any information about me in accordance with the terms of this consent for as allowed by law. *
Required
Electronic Signature *
Parent/Guardian First and Last Name
Your answer
Youth Sign-Out Policy
It is the general practice at Teen R.E.A.C.H. that youth are able to sign out of programming and leave the premises at their own discretion. However, if you would like to make changes to this arrangement with your child, that can be arranged. Please indicate your preference:
*
Educational Presentations

One of the many goals of having a program like Teen R.E.A.C.H. in place is to educate the youth about the risks and dangers they may face in our world today, and how to avoid them. Therefore, we occasionally have guest speakers come to the Teen R.E.A.C.H. Center and present information to the youth in an age-appropriate way. Some topics include (but are not limited to):

---Internet Safety/Cyberbullying ---Bullying
---“Sexting” and other cell phone issues
--- Inappropriate Touch Awareness/Sexual Abuse
__Drugs/Alcohol/Tobacco

The hope is that speaking openly and honestly with the youth about some of these issues will equip them with the skills they need in order to make good decisions. The youth will also learn how to get help for themselves and others if they are ever faced with a difficult situation.

*
Your answer
Youth Information
What are your child's future aspirations/plans after high school? *
Please check all that apply *
Required
Transportation
Transportation is being offered from each school in Clay County at no cost.

North Clay Elementary/Junior High - CEFS bus will pick up students at approximately 3:10 p.m.

Clay City - Health Department van will pick up students at approximately 3:05 p.m.

Flora - **Parents can request to have their bus route changed to make the Washington School their child's drop off site** PLEASE CALL THE BUS BARN at 618-662-4272 to make this request.

Full Armor - CEFS bus will pick up students at approximately 3:20 p.m.

Return transportation is NOT available at this time. Students must be picked up no later than 6:00 p.m.

In cases of inclement weather or dangerous driving conditions, the health department van may not be transporting youth. Parents should listen to WNOI for any announcements.

Youth are expected to be on their best behavior while riding the buses or the van. Poor behavior may result in a suspension from transportation services.

Please check with transportation option your child will be using:
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