NSBE Atlanta Professionals District Wide NSBE Jr.
Event Timing: 9am-12:30 pm Saturdays (Bi-Weekly)-Starting Sept 29, 2018 to April 20, 2019
Registration fee: $150
Event Address: 1492 Kelton Drive, Stone Mountain, GA  30083
Contact us at 770-861-7409 or pci@nsbeatlantaprofessionals.org
Email address *
Child's First Name *
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Child's Last Name *
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Child's Date of Birth *
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Child's Gender *
What grade is your child in? *
Parent/Guardian Full Name *
Your answer
Relationship to Child *
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Please list any other students you are registering (*NOTE* Each student MUST be registered separately. A separate application MUST be filled out for each student)
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Parent Email *
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Phone Number *
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Home Address (Address, City, State, Zip Code) *
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What type of school does your child attend ? *
School Name *
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School's City, State, and Zip Code *
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Child's Race & Ethnicity *
Required
Please list any medical/mobility/mental health concerns of which we should be aware of. The program will accept children with moderate special needs as long as the program can reasonably accommodate their needs and their presence does not endanger the health and safety of other children and the staff. Volunteers are not professionally trained or certified to handle certain types of behaviors. Place "N/A" for not applicable *
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Please list any allergies your child may have and their symptoms. *
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Does your child need medication during the District Wide NSBE Jr. hours ? Note: Program hours are from 9-12 pm. *
Notice to Parents Regarding medications. I agree that the Atlanta Professionals District Wide NSBE Jr. program, its volunteers, as well as its associated agents, shall not be held liable for any injury resulting from my child's possession and self-administration of the above-described medication while on program grounds. I understand that all prescription medications provided to my child during the Atlanta Professionals District Wide NSBE Jr. program, must be labeled by the pharmacist and in the original container and all over the counter medications must be in original containers.I understand that to properly administer my child’s medication, Atlanta Professionals District Wide NSBE Jr. staff members may require clarification to provide assistance. I understand that classroom staff members are designated non-medical school personnel and may assist in carrying out written orders, under supervision, of the Atlanta Professionals District Wide NSBE Jr. programs Site Leadership Team. You must notify the Atlanta Professionals District Wide NSBE Jr. Program immediately and submit a new form if there are changes in medication, dosage, time of administration, and/or the prescribing authorized health care provider. I give permission for the Atlanta Professionals District Wide NSBE Jr. program to exchange medication-related information with site-specific staff members. *
Please list any medications your child takes and the condition the medication is for *
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Emergency Contacts w/phone number and relationship to child (Must be different than Parent/Guardian) *
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Is your child a NSBE Jr. member ? *
T-Shirt Size? (Note: T-shirts are in Adult sizes) *
NSBE Jr. Member Information (Chapter Name and ID number) *
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Do you qualify for APEX membership?: High School NSBE Jr. members with a GPA of 3.5 or better. Please bring copy of transcript to the first meeting for verification. APEX members are eligible for discount registration and a special reception at National Convention. *
Photo and Video Authorization: I hereby acknowledge and grant the Atlanta Professionals District Wide NSBE Jr., its photographers, videographers, representatives, and employees the final right and permission, to take photographs, and/or videos of me and/or my child while engaged in Atlanta Professionals District Wide NSBE Jr. activities; with the right to copyright, use and publish in print and/or electronically for program marketing purposes only. *
Authorized Pick Up: List any individuals who you authorize to pick your child up from the program. Note: Each parent and authorized individual is required to show a valid ID EACH day for pick-up and the first day of camp. AT LEAST (1) REQUIRED AUTHORIZED PICK-UP *
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Parent/Guardian Consent and Agreement for Emergencies: Every effort will be made to notify parents immediately in case of emergency. In the event of an emergency, and the Parents are not reachable your listed emergency contact will be notified. I hereby give permission to Atlanta Professionals District Wide NSBE Jr. program to secure and authorize emergency medical care and/or treatment to my child who might require while under the supervision of Atlanta Professionals District Wide NSBE Jr . I further authorize Atlanta Professionals District Wide NSBE Jr. to administer emergency care/treatment(CPR/First Aid) deemed necessary, until medical assistance is available. I also agree to pay all costs and fees contingent of any emergency medical care and/or treatment for my child. I consent for the emergency contact person (s) listed above to act on my behalf until I am available. Please type your FULL name *
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My child will travel to and from the program by *
Required
Discipline Policy and Parent/Guardian Code of Conduct: It is our intention to provide your child with a safe and secure environment. We attempt to create a warm, comfortable and fun environment that will make your child look forward to coming to NSBE Jr each month. In order to ensure the quality of this program and safety of all students and staff, each student must follow the program rules. Students are encouraged to practice social skills that will allow them to resolve conflicts and meet their needs without the use of harmful or destructive behaviors. Program staff will make every effort to ensure all students have a positive experience at District Wide NSBE Jr. events. When a student does not follow the behavior guidelines, we will take the following action steps. General Behavior Rules: 1) Show respect to all participants, Atlanta Professional District Wide NSBE Jr. staff, school officials, program equipment and facilities. 2) Keep hands, feet, your head and other body parts to yourself. 3) Use appropriate language at all times. 4) Listen and follow instructions. Discipline Policy: 1) Verbal warning with redirection 2) Time-out/Activity: Withheld where student reflects on his/her behavior. Student fills out a "Timeout Notice" identifying the problem and creating a solution. Timeout notice will be given to parent at the time of pickup. 3) Written warning: Mentor completes a "Warning Notice Form" Mentor files "Warning Notice Form" and gives a copy to the parent Parent will be notified at time of incident 4) Suspension: Site Leader completes a "Suspension Notice Form" Parent/guardian will be called to pick up their student immediately. Child will be suspended from the program for the remainder of that day and the following day. 5) Withdrawal from Atlanta Professionals District Wide NSBE Jr. program. PLEASE NOTE: If your student receives 2 suspensions, he/she will be automatically withdrawn from the program.They will not eligible to return to the program for the remainder of the program. A Withdrawal Form will be completed by the Site Leader. Student must be picked up immediately. Student will be eligible to register for Atlanta Professionals District Wide NSBE Jr. the following year, but only upon the approval of a WHQ PCI representative. Grounds for Immediate Dismissal: Physical violence or bullying/teasing toward another student or staff including hitting, fighting, theft, destruction of property, etc. Any child who harms himself or another (physical and/or verbal), refusing to follow the behavior guidelines, using profanity, vulgarity or obscenity, refusal to participate in activities or cooperate with staff, leaving the program without permission. Parent/Guardian Code of Conduct: Parents/guardians are expected to follow the program rules, display professionalism in all inquiries and disputes. Treat all participants and staff with respect. All program and/or staff issues, comments or concerns should be directed to the Site Director and/or WHQ PCI Team, not Atlanta Professionals District Wide NSBE Jr. Volunteers. Parents/guardians that become hostile, verbally abusive or threaten staff, NSBE Jr. participants or another parent/guardian will be asked to leave the program immediately. This includes sarcasm, criticism, yelling, screaming and/or negative comments. If you are asked to leave the program, this will result in your child being withdrawn from the program. Please address personal matters with program leaders away from students and other parents. * Program staff reserve the right to call the authorities to remove any parent/guardian who appears out of control. *
By filling out this registration form, you are acknowledging the Liability Release and Parental Consent Form: In consideration of the acceptance of my child’s application for the Atlanta Professionals District Wide NSBE Jr. program, I hereby waive, release, and discharge all claims for damages including personal injury, and property damages that may hereafter occur to my child or myself, as a result of participation in the Atlanta Professionals District Wide NSBE Jr. program. This release is intended to discharge the Atlanta Professionals District Wide NSBE Jr. program in advance as well as its employees, school facilities, associated agents and the National Society of Black Engineers (NSBE) from liability, even though that liability may arise out of perceived negligence. It is understood that some activities and or equipment at the Atlanta Professionals District Wide NSBE Jr. program may involve some risk or danger of an accident. Knowing those risks, I assume those risks. It is understood and agreed that my signature on this waiver is a condition of my child’s acceptance into the Atlanta Professionals District Wide NSBE Jr. program.I give consent for my child to participate in the Atlanta Professionals District Wide NSBE Jr. program. I also give my consent to have the above participant treated by emergency medical personnel, a physician, or surgeon, in a case of sudden illness or injury while participating while at the Atlanta Professionals District Wide NSBE Jr. program. It is understood that the Atlanta Professionals District Wide NSBE Jr. program will not provide medical insurance and any other form of insurance for such treatment and that the cost will be at my expense. I have read and understand the Liability Release and Parental Consent Form, and agree to all of its terms and conditions. *
Parents are required to volunteer at least 4 hours to assist with the District-Wide NSBE Jr. Programming. Please select the following date(s) that you will volunteer. (required) *
Required
Parents are required to volunteer at least 4 hours to assist with the District-Wide NSBE Jr. Programming. Please select from the following roles available for parent volunteers:
Parents are an essential component to a successful NSBE Jr. Chapter. In addition to monthly meeting programming for academic enrichment and the 3C's (Character, College and Career) development, students will also have the opportunity to prepare for national competitive events. More information on Competitive events can be found at: https://gallery.mailchimp.com/681715049abec35bbfbfbb89f/files/ab90ca30-7e07-4689-b82b-89878002b7d7/2017_2018_PCI_Rule_Book.pdf Please indicate which of the following competitions you will be willing to offer assistance: *
Required
In addition to our monthly programming meetings, there are Regional and National Conventions which require overnight travel please indicate your interest in your child traveling with the District Wide NSBE Jr. Chapter
Parents are an essential component to a successful NSBE Jr. chapter. In addition to our monthly programming meetings, there are Regional and National Conventions which will require overnight travel and Parent Chaperones. Please indicate your ability to chaperone one or more of the following events.
Attendance is essential to successful outcomes of our programs. Students are allowed no more than two (2) consecutive absences and no more than a total of four (4) absences for the entire programming. *
We have made every effort to add exciting robust programming this year to gauge the interest of our students. Please list specific topics your child may have interest in for in the following areas: STEM/STEAM, Academic Enrichment, Competition, and 3C’s (Character, College and Career Development). *
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A copy of your responses will be emailed to the address you provided.
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