Family Application

Family Application

Contact Number: 1-718-498-4900
Current Date:
Programs

(Please indicate which program you are registering for.)
Financial Literacy Steel Pan Workshop Academics/Homework Help
It is mandatory to submit Proof of Address with your application.
Accepted By:
Date:
INTAKE STAFF

Medical Form Proof of Address Signed Waiver

Email: info@eliteoneskids.org Web: www.eliteoneskids.org

Applicant Information
First Name:
Last Name:
Date of Birth:
Gender

Male Female
Address:
Street Address:
Complete Street Address
Apt #:
City:
State:
ZIP Code:
Email Address:
example@example.com
Home Phone #:
Cell Phone #:
Contact Information
Parent/Guardian:
Relationship:
Home Phone #:
Work Phone #:
Cell Phone #:
Other Parent/Guardian:
Relationship:
Home Phone #:
Work Phone #:
Cell Phone #:
Please List 2 Other Relatives/Friends
Relative/Friend #1
Name:
Relationship:
Contact Phone #:
Address:
Street Address:
Complete Street Address
Apt #:
City:
State:
ZIP Code:
Relative/Friend #2
Name:
Relationship:
Contact Phone #:
Address:
Street Address:
Complete Street Address
Apt #:
City:
State:
ZIP Code:
Any known Medical/Health Alerts/Allergies?

Yes No
If you chose "Yes", please list:
Does the child have any medical condition that affects his/her participation in physical activities?

Yes No
If there is a person who CANNOT have access to the child, please indicate.
Name:
Relation:
The person listed above have my permission to be responsible for my child in case of an emergency in my absence.
Signature of Applicant:

Clear
Print Name:
Date:

Codes Of Conduct
Adherence to T.E.O.O. Regulations is mandatory to ensure a safe and healthy environment for all participants. Children enrolled in T.E.O.O. Programs are on a probationary basis for 4 weeks. You and your child must demonstrate compliance with T.E.O.O.'s Regulations in order to remain active participants in the program.
Parent/Guardian Initials (required):
HOURS OF OPERATION
T.E.O.O.'s programs will operate all year except for vacation. The program's schedules would be determined by Elite Ones staff as necessitated by the demands of our community. The schedule would be posted in a timely manner for families to make adequate arrangements.
1. Participants must sign-in daily and must sign out as well. Participants may only sign-in for the current day.
2. Participants must wear appropriate clothing and shoes. All hats ( except those used for religious purposes) must be removed upon entering. No Hoodies.
3. Students must refrain from inappropriate interactions.
4. Foul language and fighting are strictly prohibited. Individuals caught fighting may have their privileges revoked. No Bullying or Teasing.
5. Disagreements must be resolved in a POSITIVE MANNER. NO VIOLENCE .
6. Eating is only allowed in designated areas and at all times. No candy, gum, or seeds.
7. Littering is not permitted in or around the facility. All garbage and recyclables must be placed in their proper containers. VANDALISM IS STRICTLY PROHIBITED .
8. Participants are encouraged to leave all electronic devices and valuables at home. We are not responsible for lost or stolen items.
9. No weapons of any sort are permitted.
10. Purchase snacks before entering the facility.
11. Ask Permission to borrow any material belonging to T.E.O.O.
12. No loitering. Leave the facility upon dismissal.
13. Follow instructions of Elite One's Staff, Respect yourself and Elite Ones Staff.
14. Applaud the efforts of others BE HONEST .
15. Leaving the facility is not permitted until dismissal.
16. No alcohol, cigarettes, or controlled substances are permitted on or around the premises.
17. Theft is subject to criminal prosecution and revocation of facility privileges.
18. All fitness and game equipment, such as mats, weighs, and controllers, must be used with care.
19. Videotaping/recording of participants' activities is not permitted.
20. You must take responsibility for your actions.
21. Respect other people's cultural, racial and ethnic backgrounds.
22. Students must be picked up on time or there will be a late fee.
NOTE:

If you are found to be in violation of our Codes of Conduct you will be suspended for ONE WEEK
On the second offense, you will be suspended for TWO WEEKS and on the third offense, you will be suspended from the program. There will be no refund of fees due to the student's suspension.
I understand The Elite Ones Organization's Codes of Conduct. I acknowledge that failure to obey these rules will terminate or suspend my participation in The Elite Ones Organization's program.
Print Name:
Participant's Signature:

Clear
Date:

AUTHORIZATION RELEASE
T.E.O.O's Programs include educational and recreational activities that necessitate continuous participation. As demand arises for registered spots in T.E.O.O.'s programs, consistent attendance would be mandatory. The following regulations apply to all T.E.O.O. programs.
1. If a child is going to be absent from T.E.O.O.'s program, the parent or guardian must call and inform a staff member.
2. If a child is going for two consecutive weeks without notifying the TE.O.O staff, a staff member will call to check if the child will continue in the program.
3. If a child is absent for four consecutive weeks without explanation, T.E.O.O. staff will assume the parent or guardian no longer wants the child to be part of the program and T.E.O.O. will give the spot to a child on the waiting list. The parent or guardian will be notified.
4. If a child is going to be picked up early or needs to leave early, the parent or guardian must notify T.E.O.O.
5. The following individuals are authorized to pick up my child/children in my absence:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
(If there is a person who CANNOT have access to the child/children, please indicate)
Name:
Relationship:
Name:
Relationship:

PROGRAMS EVALUATION
T.E.O.O.'s Program, staff, and youth experiences will be assessed in efforts to continuously improve the program. Children may be asked to complete questionnaires about their experiences at various times throughout the year. Their responses are anonymous and individual results will not be shared or published. Only group summary information may be used to provide feedback for program providers. Signing this form gives content for your child to answer questions on such surveys.

AUTHORIZATION TO PRODUCE AND USE AUDIOVISUAL MATERIALS

I hereby voluntarily and without compensation authorize TEOO, Inc. to produce photographs, movies, videotapes, audio-tapes, and PowerPoint Presentations of the below-named student. The authorization is given on the condition that the materials taken or produced will be used for the purpose of community education or program promotion. I understand TEOO, Inc. and its employees will not use these materials for compensation.

I understand that this grant of permission shall only be revoked by a written instrument delivered to the Executive Director of TEOO, Inc. This consent shall remain in full effect unless revoked.

HOLD HARMLESS WAIVER

I hereby waive, release and absolve, indemnify and agree to hold harmless The Elite Ones Organization, its directors, staff, organizers, sponsors, participants and any other affiliates for, from and against all liability because of any bodily injury, or property damage, known or unknown, which may occur or result from the participation of the above named child in any and all activities whether the result of negligence or for any other cause of The Elite Ones Organization I individually and as a part guardian for my child, have read this release and understand all the terms I execute it voluntarily and with full knowledge of its significance.
Date this release have been made:
Name of Student:
Name of Parent/Legal Guardian:
Parent/Guardian Signature:

Clear
Date:

PAYMENT PLAN
Date:
Student Name:
Beginner Intermediate Advanced
How did you hear about us:
Name of Workshop:
Duration:
Payment Type:
Cash ($)
Check (#)
Credit/Debit Card

Click here to make a payment with credit or debit card
Make checks payable to: Elite Ones
CANCELLATION/REFUND POLICY
Total Cost:
Deposit:
Balance:
2nd PAYMENT:
Balance:
Final Payment:
Parent/Guardian Signature:

Clear
Student Signature:

Clear
Registration Completed By:

Fitness Liability Waiver
I hereby waive, release and absolve, indemnify and agree to hold harmless The Elite Ones Organization, its directors, staff, organizers, sponsors participants and any other affiliates for, from and against all liability because of any bodily injury, or property damage, known or unknown, which may occur or result from the participation of the above named child in any and all activities whether the result of negligence or for any other cause of The Elite Ones organization I individually and as a parent guardian for my child, have read this release and understand all the terms I execute it voluntarily and with full knowledge of its significance. I am physically fit to exercise and have obtained any necessary medical clearance from my physician prior to beginning or continuing any physical activity. In the event that I am injured in any way or suffer any medical condition as a result of participating in The Elite Ones program, and on behalf of myself, my heirs, agents or assigns, I hereby waive any claims, demands or cause of action and release from any liability whatsoever, The Elite Ones Organization and their agents.
Print Name:
Participant's Signature:

Clear
Date:
Photo/Video & Fitness Liability Waiver
I certify and understand that The Elite Ones Organization staff as well as photographers, newspaper and television reporters, media representatives and public relations personnel may photograph, or record those who participate in these activities and events and the resulting images, videos, and interviews may be used to promote the programs.
Therefore, I give permission for my likeness to be photographed, interviewed or otherwise recorded and the resulting images and text may be used by The Elite Ones Organization in any medium, whether now or hereafter:
Signature of Parent/Guardian:

Clear
Date:
I do not give permission for photographs, other recordings or interviews to be used by the programs of The Elite Ones Organization in any publication. As a result, I may not be able to participate in events and group activities that may be used for publication purposes.
Signature of Parent/Guardian:

Clear
Date:
I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the programs. In addition, I am physically fit to exercise and have obtained prior necessary medical clearance from my physician. In the event that I am injured in any way or suffer any medical condition as a result, on behalf of myself, my heirs, agents or assigns, I hereby waive any claims, demands or cause of action and release from any liability whatsoever from The Elite Ones Organization.
Signature of Parent/Guardian:

Clear
Date:
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm