Hyde Square Task Force Program Enrollment Form

Thank you for your interest in joining our programs! We are so happy you are going to be a part of Hyde Square Task Force!

If you are enrolling in JEA or Caminos and attend school, we will ask you to upload a copy of a recent report card or progress report.

If you are enrolling in JEA or Caminos, we will ask you to upload proof of residency and proof of income documents.

If you have any other questions about enrolling, please reach out to recruitment@hydesquare.org.

Participant Information

Participant First Name

Participant Last Name

Participant Email

What program(s) are you enrolling in?

Artes CulturalesCaminos

Jóvenes en Acción (JEA)

Living Safely in Jackson Square Youth Organizing

Is the participant 18 years or older?

Academic Information

Please use this space to inform us of any learning, behavioral, or emotional support needs you have that our staff should be aware of. If none, write "none" below.

Do you have an IEP?

IEP stands for Individualized Education Program. The purpose of an IEP is to lay out the special education instruction, supports, and services a student needs to thrive in school. IEPs are part of PreK–12 public education.

Do you have a 504 plan?

504 plans are formal plans that schools develop to give kids with disabilities the support they need. 504 plans often include accommodations. Accommodations don’t change what kids learn, just how they learn it. The goal is to remove barriers and give kids access to learning.

Academic Information (to be completed by the participant and Parent/Guardian)

Please use this space to inform us of any learning, behavioral, or emotional support needs your child has that our staff should be aware of. If none, write "none" below.

Does the participant have an IEP?

Does the participant have a 504 plan?

Emergency Contact Information

Please provide the contact information for at least one person we can reach out to on your behalf in case of an emergency. This can include parents, other family members, significant others, roommates, friends, or others.

First and Last Name - Emergency Contact

Relationship to Participant - Emergency Contact

Phone Number - Emergency Contact

Would you like to provide an additional emergency contact?

First and Last Name - Additional Emergency Contact

Relationship to Participant - Additional Emergency Contact

Phone Number - Additional Emergency Contact

Emergency Contact Information (to be completed by the Parent/Guardian)

Parents/Guardians, we received your contact information in the initial program application and you will always be our first emergency contact. This section is to provide an alternate contact person in case we cannot reach you in an emergency.

First and Last Name - Emergency Contact

Relationship to Participant - Emergency Contact

Phone Number - Emergency Contact

Would you like to list another emergency contact?

First and Last Name - Additional Emergency Contact

Relationship to Participant - Additional Emergency Contact

Phone Number - Additional Emergency Contact

Medical Documents Upload (Optional)

If you have any medical plans/documents you would like to share with us (ex. allergy plan, asthma plan), you can upload them here. This is optional.

Income Information and Verification

We are asked to collect the following information as a condition of the funding that we receive from the Mayor's Office of Workforce Development (OWD). This information is confidential and is used to verify that OWD funds benefit eligible Boston residents. Please fill all of the information out for the program participant's household.

How many people live in your household?

1 Person: Select the income range that best describes your household.

2 People: Select the income range that best describes your household.

3 People: Select the income range that best describes your household.

4 People: Select the income range that best describes your household.

5 People: Select the income range that best describes your household.

6 People: Select the income range that best describes your household.

7 People: Select the income range that best describes your household.

8 People or More: Select the income range that best describes your household.

Income Verification

Proof of Residency

Additional Information (to be completed by the participant)

If you selected "something else" please describe below.

What is your t-shirt size (unisex adult sizing)?

What is the highest level of education earned in the United States by either one of your parents? Answer this question only for the parent who has the highest level of education, and only for education/degrees in the United States.

Consents

Select an option below for each. The signature and date at the end will apply to all four consents.

Release of School Records: As a part of HSTF programming, you will receive free educational support. To help us with this, we ask that you share access to your grades, so we can support you academically. For participants who are in high school, we will review grades twice per quarter. For participants who are attending a college, university, or other post-secondary program, we will request evidence of academic progress (such as unofficial transcripts or mid-term grades) approximately twice per semester. The Release Information is as follows: I give my consent and authorization for the release of my school and classroom records to the staff of Hyde Square Task Force (HSTF). If HSTF is unable to obtain these records directly from my school, I agree to provide them upon request. I understand that all information and records will be kept confidential and used only for academic coordination and assistance. The records being requested include, but are not limited to Attendance Records, Report cards and Progress Reports, Class schedules, Standardized Test Scores, Individual Education Plans and/or 504 Plans (if applicable).

You have my school consent.You DO NOT have my school consent.

Medical Consent: I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take me to a hospital and secure medical treatment for me when delay would be dangerous to my health.

You have my consent.You DO NOT have my consent.

Release and Waiver of Liability Agreement for Participation: This agreement is by and between Hyde Square Task Force and the individual whose name is signed and printed below (herein referred to as participant). I hereby agree to the following:

1. I am participating in a Hyde Square Task Force program, during which I will participate in physical activity workshops. I recognize that participation in such activities requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any Hyde Square Task Force program. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in any Hyde Square Task Force program.

3. In consideration of being permitted to participate in any Hyde Square Task Force program, 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 program.

4. In further consideration of being permitted to participate in a Hyde Square Task Force program, I knowingly, voluntarily, and expressly waive any claim I may have against Hyde Square Task Force and its employees, board members, officers, volunteers, and staff for damages, and injury, including death, that I may sustain as a result of participating in the program.

5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue Hyde Square Task Force and its employees, board members, officers, volunteers, and staff for any injury or death caused by my voluntary participation in any Hyde Square Task Force program.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as I participate in any Hyde Square Task Force program.

I agree.

Consents (to be completed by the participant and Parent/Guardian)

Select an option below for each. The signature and date at the end of this section will apply to all four consents.

Release of School Records for Participant: As a part of HSTF programming, the participant will receive free educational support. To help us with this, we ask that you share access to the participant's grades, so we can support them academically. For participants who are in high school, we will review grades twice per quarter. For participants who are attending a college, university, or other post-secondary program, we will request evidence of academic progress (such as unofficial transcripts or mid-term grades) approximately twice per semester. The Release Information is as follows: I give my consent and authorization for the release of my school and classroom records to the staff of Hyde Square Task Force (HSTF). If HSTF is unable to obtain these records directly from my school, I agree to provide them upon request. I understand that all information and records will be kept confidential and used only for academic coordination and assistance. The records being requested include, but are not limited to Attendance Records, Report cards and Progress Reports, Class schedules, Standardized Test Scores, Individual Education Plans and/or 504 Plans (if applicable).

You have my school consent.You DO NOT have my school consent.

Medical Consent: I hereby give Hyde Square Task Force permission to administer basic First/Aid and/or CPR and/or take my child to a hospital and secure medical treatment when I cannot be reached or when delay would be dangerous to my child's health.

You have my consent.You DO NOT have my consent.

Release and Waiver of Liability Agreement for Participation: This agreement is by and between Hyde Square Task Force and the individual whose name is printed below as the participant(herein referred to as participant), and the parent/guardian of the participant. As the parent/guardian of the participant, I hereby agree to the following:

1. My child is participating in a Hyde Square Task Force program, during which they will participate in physical activity workshops. I recognize that their participation in such activities requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my child's participation in any Hyde Square Task Force program. I represent and warrant that they are physically fit and they have no medical condition that would prevent their full participation in any Hyde Square Task Force program.

3. In consideration of being permitted to participate in any Hyde Square Task Force program, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which my child might incur as a result of participating in the program.

4. In further consideration of being permitted to participate in a Hyde Square Task Force program, I knowingly, voluntarily and expressly waive any claim I may have against Hyde Square Task Force and its employees, board members, officers, volunteers, and staff for damages, and injury, including death, that my child may sustain as a result of participating in the program.

5. I and my heirs or legal representatives forever release, waive, discharge and covenant not to sue Hyde Square Task Force and its employees, board members, officers, volunteers, and staff for any injury or death caused by my child's voluntary participation in any Hyde Square Task Force program.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. This agreement remains in effect for as long as my child participates in any Hyde Square Task Force program.

I agree.

Report Card Upload

Please upload a recent report card, progress report, or screenshot of academic information.

Consents and Signatures

Participant Signature

Parent/Guardian Signature

Today's Date

MM/DD/YYYY

Contact Information