KEYS Scholars Program

KEYS offers access to an array of activities that develop team building, life skills, and non-traditional approaches to healing. Activities are offered during out-of-school time and promote peer-to-peer bonding through strengths-based communication techniques.

Providing cultural enrichment opportunities for school-aged youth through out-of-school, summer, and after-school activities.

Step 1 of 5

Site Location(Required)

Other:(Required)

Please list the location.

Placement:

Who is making this referral:(Required)

Is this a follow-up registration?

Please select YES if an initial referral was previously received from the school or community.

Name:(Required)

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COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

The safety of our employees, students, families, and visitors remains KEYS' priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to all parties, we are conducting a simple screening questionnaire with this waiver. Your participation is important to help us take precautionary measures to protect you, your Child(ren) and everyone on campus.

	Yes	No
Has your child had close contact with or been diagnosed with COVID-19 within the 30 days?
Has your child experienced any of the symptoms below in the last 14 days? (fever, chills, cough, sore throat, respiratory illness, difficulty breathing, or loss of taste or smell)
If my Child(ren) develop(s) any of the above symptoms I will keep them home, notify a KEYS Staff and seek medical care to obtain a physician’s note stating it is safe to return to participation.

KEYS programming is provided in a manner in which emotional and physical health is of utmost importance. For programming, KEYS will not enforce a mask mandate. Each youth and family is encouraged to discuss the decision that works best for you and your family.

KEYS will provide Personal Protective Equipment (mask, gloves, hand sanitizer wipes, etc.) to those who would like some. These items will be made available both onsite and during off-campus events.

The KEYS has put in place protective measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending activities with KEYS could increase your risk and your child(ren)’s risk of contracting COVID-19.

MEDICAL INFORMATION

Please list any food allergies or dietary restrictions:(Required)

Does this scholar require medication that is needed during these hours?(Required)

Does this youth have any health concerns that need to be acknowledged, if so please list?(Required)

Current Primary Care Provider Name:(Required)

Primary Care Provider Contact Number:(Required)

Insurance Provider Name:

Insurance Card Number:

CONSENT

As the parent/guardian, I give permission for my child to be transported by KEYS Empowers, LLC. I understand that staff of KEYS Empowers, LLC will take all reasonable precautions while transporting my child but cannot be held accountable for unavoidable accidents.(Required)

I give permission for myself/my youth to participate in KEYS Programming. I give permission for myself/my youth to hold conversations that discuss mental health, police brutality, healthy sex practices, positive peer relationships, and other topics that provide support and promotion for healthy development.(Required)

If I choose to consent and authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form). I authorize KEYS to copyright the materials, and I authorize KEYS to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I agree with these items to be used up to 99 years after the initial date of use. I agree that I am participating on a voluntary basis and I will not receive any payment from KEYS for signing this release or as a result of any publication of the materials. If I choose to be photographed or recorded, I do not consent or authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).(Required)

I, hereby agree to release and hold harmless from any liability, KEYS including its paid and volunteer staff executors, administrators, and other agents representing KEYS. This waiver specifically relates to personal injury which may occur while participating in any programs or activity of any kind conducted, approved, organized, or sponsored by KEYS or its representatives. Further, that the consideration for this waiver, is the right, privilege, and opportunity for myself/my child to participate in the programs and activities conducted, approved, organized, or sponsored by KEYS.(Required)

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending activities with KEYS and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 while engaging in KEYS programming may result from the actions, omissions, or negligence of myself and others, including, but not limited to, KEYS employees, visitors, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance in activities or participation in KEYS programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless KEYS, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of KEYS, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any activity.

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Youth Dismissal:(Required)

I give permission to have my child walk home by him/herself.

I give permission for my child to walk home with friend or sibling.

I will be picking up and dropping off my youth.

Mark only one oval

Signature:(Required)

Email:(Required)

DEMOGRAPHIC INFORMATION

TRANSPORTATION

Current Needs

EMERGENCY CONTACT INFORMATION

COVID-19

MEDICAL INFORMATION

CONSENT