Student Registration - Avenue 941
Please compete one form for each student.

Eligibility Requirements
(must be at least one of the following)
1. The student must be struggling academically
2. The student must either attend a public title 1 school in Manatee County or be eligible for free/reduced lunch
3. The student must be a foster child or come from a single parent household without access to tutoring, mentoring or discipleship
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Which eligibility requirement do you meet to be a part of our program? (Select all that apply)
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Required
The location I want to register my student for is: *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Email *
Parent/Guardian Phone Number *
Where or from whom did you hear about this opportunity? *
The best way to reach me is: *
Please list all the names of the people who have given consent to pick up your child. *

Does your student have permission to leave this campus by himself/herself at dismissal?


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What other contact information do we need if any (list names with phone numbers)?
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Student First Name
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Student Last Name
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Student Grade Level

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Student Birthday *
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Student's Ethnicity *
Required
Student's School Name *
By registering your child, you give permission to us to access FOCUS to monitor grades and school work. We will need your student's FOCUS log-in information so that we can help them log in to complete their work. Type username here (typically is the student ID number starting with 415)
What is your student's FOCUS log-in Password

Is your student able to attend every week twice/week? (regular attendance is required) If your student misses 3 or more tutoring sessions, they are at risk of losing their spot in the program.

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Does your student have transportation or a way to and from the location you chose?

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We often provide snack and/or dinner. Does your student have any food allergies that we should be aware of? If so, what?
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Does your student need any medication or have any medical issues or health concerns that we should be aware of? If so, what?
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What does your student need most from a program like this in your opinion?

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Required

Does your student have any of the following plans at school?

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Is your student part of the ESOL or ELL dept in his/her school?

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We have a partnership with Samaritan Counseling and at some locations we offer group education through an intern from their organization. Would you be interested in signing your student up for individual 25 minute counseling sessions one time per week while they are on site with us?
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Would you be interested in free private counseling through Samaritan Counseling off site?

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Please check if you also need support with the following resources so that we can refer you to other organizations who support our families through the Unite Us platform:

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Required
I have read and agree with the Code of Conduct and my student will comply with the rules of the program.
*

I understand that by completing this questionnaire, my students will hear Biblical content as this is a faith-based program, that I am granting access to FOCUS and that my student may have pictures and videos taken of them as part of community building and social media.

*

Participation Agreement: I understand that by participating in this activity, the Student/Participant is required to consent and abide, by all the guidelines, procedures and decisions run and established by the Avenue941 Leadership, Student Ministry Leaders and Volunteers. Non-compliance of a guideline, procedure and timely conformity to a leadership decision may result in the following: Parent/Guardian will be called to immediately pick-up Student/Participant; participation in future Student Ministry and other Avenue941 activities may be limited and/or not allowed; other appropriate measures which are deemed necessary for the safety of the Student, Avenue941 and the Student Ministry. The Student and Parent/Guardian understand, agree and consent, that Avenue941, Student Leaders and volunteers have no responsibility for, and are not obligated in any way, now or in the future, to provide financial, and other type of assistance for, personal injury, personal property loss or damage during their time at one of our host churches (Resonate Life Church, Oneco United Methodist Church, Gulf Coast Church, 180 House, First Baptist Church or Oasis Church. 

The Student/Participant and Parent/Legal Guardian agree to be responsible for any damage caused by the Student to equipment, supplies and other resource, and will immediately make all requested restitutions to, at Avenue941 option, obtain, repair all/any damage caused. 

Release and Indemnification: I recognize that by participating in Student Programs and Activities, as with any group activity, my student may risk serious, or even fatal, personal injury. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in Student Programs and Activities, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. I, for myself, my child, my executors and assigns, further agree to release and forever discharge Avenue941 and its staff, leaders and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any injury, damages, demands or actions whatsoever, including those resulting from negligence by Avenue941 and its staff, leaders and volunteers, in any manner. All matters regarding non-compliance of the statements expressed in this form will be first submitted for decisions by Avenue941 Leadership, Avenue941 Board, and, if further decided by Avenue941 Leadership, Christian arbitration with a competent arbiter chosen by Avenue941 in accordance with any Bylaws. Any and all matters pertaining this and other activities of Avenue941 are subject to the State of Florida laws. Student/Participants consent and agree that, if they would use the State of Florida court system, all legal requests will be handled by one of its official courts in the northern Virginia counties. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. 

Medical Treatment Consent: I, being the parent/guardian of the said student, understand that while every precaution will be taken to ensure the welfare and protection of my student, Avenue941, its staff, leaders and volunteers acting on my behalf, as a service to my student and all participants, may assist in getting medical health help, and are hereby completely released from any and all liability, indemnity and restoration request, now and in the future, in the event of any accident or misfortune that may occur to my student/participant. 

In the case of an emergency, I hereby give permission for medical treatment and/or transport by Avenue941 and/or First Responders to ensure proper treatment for my student. I understand that every effort will be made to contact me before instituting such procedures. I agree to pay, and reimburse all such doctor, ambulance, hospital, and other related fees incurred on behalf of my student. 

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Parent/Guardian Name as Signature *
Date of Registration *
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Intending to glorify God in all we do (1 Cor 10:31), Avenue941 endeavors to comply with all pertinent federal, state and local laws that preserve the right to privacy and personal information. Avenue941’s Information practice conforms and governs the collection, maintenance, use, and dissemination of personally identifiable information (PII) about individuals and families and is strictly maintained in secured systems of records. Avenue941 strives to manage information, data, and processes, and do its activities with integrity and excellence.  Untitled Title
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