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RegisterAdmin2021-08-09T23:56:51-07:00

Registration for H4H programs, youth under 18 yrs old.

"*" indicates required fields

AFTERSCHOOL REGISTRATION
# students?
Please enter a number from 1 to 2.
Student Name*
Date of Birth*
Location Requested
Gender*

Please describe any allergies (nut, foods, dust etc); and any medications the child takes.
Please also describe any activities your child may not participate in, and anything else we need to know to serve your child.
How does the child identify their ethnicity?

STUDENT 2

Student 2 Name*
Location
Student 2 Gender*

Student 2 Date of Birth*
Please describe any allergies (nut, foods, dust etc); and any medications the child takes, and anything else we need to know to serve your child.
How does the child identify their ethnicity?

Contact and Emergency Information

Parent or Guardian Name*
Address*
Is there a second parent/guardian?
Additional Adult who is authorized to pick up your child / children?
(if applicable)
Second Additional authorized adult?
(if applicable)
Would you like to be part of our monthly parent support workshops ?*

Do you need help with transporting child/children from school to our Otsego Street location? If no, skip this section!

We have limited seats and routes available, for the Main Site (H4H on Otsego Street) only. Transportation is not guaranteed, and we will let you know ASAP if we are able to assist. You will still need to pick up your child at the end of the H4HLA program. Cost is $5 per week in advance, and payable via paypal/creditcard checkout online, or in cash in person.
Student 1 requests transportation on these days:
Student 2 above on these days:

LAST SECTION: demographics/survey

Thank you SO much, in advance, for completing these next questions.
Hands4HopeLA receives grants that require we provide statistics, using only combined and anonymous results of these survey questions.

Your responses help decide what kinds of programs and assistance are offered and funded.
Annual Income in your household*
Do you need any assistance with the following:*
Does your family participate in any of the following programs? CalWORKs, Calfresh, Kin-GAP, FDPIR, WIA.*
Does student qualify for free or reduced lunch?*
Are you a Veteran?*
What sex were you assigned at birth?*
M, F, Non-Binary...other...or Decline to Answer
Do you have any disabilities?*
Fee Policy
- Late Student Pick Up*
Hands4Hope program ends at 6:30 PM sharp. Prompt pickup is vital. Our staff have other work and personal obligations that begin at 6:30pm, so if your child has not been picked up by 6:30pm, Hands 4 Hope LA incurs extra costs to pay for supervision past that time.

Please consider the weather and traffic conditions. It is a good idea to create an alternative pick-up plan with your neighbors, relatives or friends to ensure on-time pick-up.


Any pickup after 6:30pm will incur a late fee, after a grace period of 5 minutes.

Fee: $5 for pickup between 6:35 and 6:40.
$10 for pickup between 6:41 and 6:50pm.

Payment is expected at time of pick up. If that is not possible, then payment will be due at "drop off" the next day. If not paid, students will not be allowed to attend the program. The program manager has sole discretion to waive fees in the event of an emergency or uncontrollable situation.

Repetitive late pick-up or non-payment of late fees may result in suspension of Hands4Hope LA After School Program.

Hands4Hope LA Afterschool Program Release Agreement & Waiver of Liability

In consideration of the services of Hands for Hope (Hands4Hope LA) and all other related entities, partners, agents, directors, advisors, officers, employees, representatives, volunteers, and all other persons acting on behalf of these entities(hereinafter collectively "Hands4Hope LA"), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge Hands4Hope LA and its representatives on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate from any and all claims, any and all auses of action that I (we) have or may have, whether past, present or future, Whether known or unknown, whether anticipated or unanticipated, as detailed in the consent boxes below.
Academic Evaluation*
I hereby give permission for the school to release any and all confidential school records to (Hands4Hope LA) for purposes of assessment and evaluation for the betterment of my child’s academic and social success and the effectiveness of
Hands4Hope LA after school program.

I also hereby give permission for my child to participate in activities or surveys designed to evaluate the effectiveness of Hands4Hope LA.
Physical Activities*
I am voluntarily participating / allowing my child to participate in instruction covering a number of topics. I recognize this may include fitness or dance classes may require physical exertion hat may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician for my child (or myself if a TAY student over 18) prior to and regarding participation in dance or fitness related instruction. I warrant that if I am aware of any medical condition that my child has that would affect participation, I will fully disclose this information to Hands4Hope LA staff in writing.
Assumption of Risk*
I understand that there is an assumed risk of injury in all (Hands4Hope LA) activities. I have read and understood this agreement, and I hereby waive all claims against Hands4Hope LA and their contractual partners for injury or damage to any person or property on and off campus premises by or from any cause whatsoever including the after school program’s negligence.

I agree to hold Hands4Hope LA and their contractual partners free from any liability or responsibility for damages arising from any injuries to myself, my child, my children, or property owned by any of us.
Release of Information*

I grant permission to Hands4Hope LA, its agents and assigns, to use my child’s name, demographic information, program outcomes, service assessments, services information for the purposes of grant reporting to Los Angeles County and other funding agencies. Hands4Hope LA is funded by several grants from various organizations and it is necessary to share basic information about program participants in order to receive funding.
Media Release*
I hereby grant permission to Hands4Hope LA, its agents and assigns, to use child’s photo or video, and likeness for the purpose of romotion by Hands4Hope LA for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website, marketing, advertising, trade, promotion, exhibition for an indefinite period of time. I further acknowledge that I will not be compensated for these uses and Hands4Hope LA owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release Hands4Hope LA and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights ofpublicity or copyright.
Walking Trips*
I hereby give permission for my child to go with Hands4Hope LA on any walking trips planned and conducted by staff. I understand that these are walking trips near the program site, and adequate health and safety precautions will be taken.



I have read the above agreement and understand fully the terms and conditions that have been explained. By signing this release agreement & waiver of liability form I am giving my child permission to attend Hands4Hope LA academic after school program.
Clear Signature
This field is for validation purposes and should be left unchanged.

Hands4Hope LA is a 501(c)(3) non-profit organization.

Federal Tax ID: 95-4791662

11210 Otsego Street
North Hollywood, CA 91601
(818) 763-HOPE(4673)
info@hands4hopela.org

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© 2013-2024 All Rights Reserved, Hands 4 Hope LA   |  Pro bono web services, Dana Marcus, J.D.  
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11210 Otsego St. N. Hollywood, CA 91601

Phone: (818) 763-HOPE(4673)

Email: info@hands4hopela.org

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