After School Program

Permission to participate in Kid’s Power and Teen Power!

An email confirmation will be sent to you with a copy of the completed form. Please use one form per child.
Which program are you registering your child for? *

Kids Power (ages 7 - 11) Teen Power (ages 12 - 17)
Today's Date? *

Month Day Year
Date
What is your child's name? *

First Name Last Name
What is your child's date of birth? *

Month Day Year
Date
What is your child's age? *
Is your child male or female? *

Male Female
What grade is your child in? *

Parent/Legal Guardian

Please read and put a mark next to the permissions you give...
I am aware of and assume all risks and wish to allow my child to participate in the activities of the Kid’s Power! Program facilitated by Central Nebraska Council on Alcoholism and Addictions, Inc. staff, Grand Island, Nebraska. As part of the consideration for my child’s participation in Kid’s Power! I agree to assume full responsibility for any loss, injury, or inconvenience that my child might experience. To the extent that I participate in such activities, I do so voluntarily and assume any and all risk of injury to my person or property resulting therefrom. I further agree to indemnify and hold harmless the Central Nebraska Council on Alcoholism and Addictions, Inc. and all its officers and staff from any and all liability incurred as a result of participation by myself or my child. I also agree that the terms here of shall serve as a release and assumption of risk for my heirs, executors and administrators, and for all members of my family. Nebraska State law requires any person who suspects or has witnessed child abuse or neglect to report the incident to local law enforcement or the Nebraska Department of Health and Human Services. *

Yes No
Medical Information: It is necessary for us to know if your child has any medical considerations and/or currently taking medications for these conditions. If so, please write YES and describe in detail. If there are no medical considerations, please write NO. *
Allergies?? (For example – insect bites/stings,medication, food) If none, write NONE) *
Names and ages of the other children in the family: (if none, write NONE) *
What is the history of the parent relationship (married, separated,divorced, single, re-married)? *
If divorced or separated, who has custody of the child? *
How frequent is visitation with the non-custodial parent? *
Are you aware of any alcohol, tobacco or other drug problems in your family? *

Yes No
If yes, please list how they are related to the child enrolled in Kid’s Power! *
What behavioral issues is the (Kid’s Power) child experiencing or are you concerned about, in school or at home? Please describe. *
Is this child currently in therapy? *

Yes No
If yes, how often do they meet with the therapist? *
Other information you’d like us to know to better assist this child:
I give my permission to have my image/voice and my child’s image/voice used by the Central Nebraska Council on Alcoholism and Addictions,Inc. (CNCAA) and/or the Heartland United Way for educational and promotional purposes. I understand that my image/voice may be used in a presentation to help illustrate and explain the educational programs of the CNCAA. Furthermore, I give CNCAA full permission to use, publish, and copyright any drawings, writings and/or stories created by me and/or my children or any part thereof, without using my and/or my child’s name, and to make changes or alterations therein and/or additions thereto for publication. *

Yes No
Electronic Signature: please type your name to sign this form.
Please note: Nebraska state law requires anyone who suspects or has witnessed child abuse or neglect to report it to local law enforcement or the Department of Health and Human Services.
The Central Nebraska Council on Alcoholism and Addictions, Inc. is a non-profit corporation supported in whole, or in part by Grant # 93.959 under the Substance Abuse Prevention and Treatment Block Grant and Grant #1H79TI081706-01 under Nebraska’s Targeted Response to the Opioid Project from the Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention and Treatment and the Nebraska Department of Health and Human Services, the State of Nebraska Department of Health and Human Services Tobacco Free Nebraska Program, and Systems of Care Private Funds through the Hall County Community Collaborative. Additional financial support is provided by Hall County, Heartland United Way, and tax-deductible donations. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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