Lankershim Elementary

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Hi! How did you hear about us?

What is your preferred language?

We ask so we can communicate effectively.

Number of Students Enrolling*

Please enter a number from 1 to 2.

You may register one or two children. If you have a third, please fill out the form again.

Student Name*

First Name Last Name

Student's Birth Date*

Student identifies as*

Male

Female

Nonbinary/Other

Student's Allergies, Medications, Physical or Mental Limitations*

Please describe any allergies (nut, foods, dust etc); and any medications the child takes, any activities your child should not participate in, and anything else we need to know to serve your child.

Grade*

Student 1 - Walk Home or to car without parental or Staff supervision?*

Yes

STUDENT 2

Student 2 Name

First Name Last Name

Student 2 Date of Birth

Student 2 identifies as

Male

Female

Non-Binary / Other

Student 2 Grade

Student 2 Allergies, Medications, Physical or Mental Limitations

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.

Student 2 School

Student 2 - Walk Home or to car without parental or other supervision?*

Yes

Household Information

Just a few more questions - thank you!

Do you participate in CalWORKs, Calfresh, Kin-GAP, FDPIR, or WIA

Yes

Do you qualify for free or reduced lunch?

Yes

Parent or Guardian Name*

First Name Last Name

Email*

Phone*

Emergency Contact*

Other than the parent/guardian above, who can we call in an emergency?

First Last

Emergency Contact's Relationship to the child(ren)

Emergency Contact Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Survey Questions which are required, but anonymized.

We receive grants that require we provide statistics, anonymous results of these survey questions. Your responses help decide what kinds of programs and assistance are provided through grant funds.

Annual Income in your household

Less than 40k

41k - 50k

51k - 60k

More than 60k

Do you need any assistance with the following:

Groceries

Utility bill payments

Other Financial assistance

Clothing

I feel hopeful about my future*

I feel like part of a community*

I know at least one thing I can do to deal with uncomfortable feelings*

I know at least one thing I can do to deal with difficult thoughts*

WHO Wellbeing Survey

Please indicate how you have been feeling over the last two (2) weeks

I have felt calm and relaxed*

All of the time

Most of the time

More than half of the time

Less than half of the time

Some of the time

At no time

I have felt cheerful and in good spirits*

All of the time

Most of the time

More than half of the time

Less than half of the time

Some of the time

At no time

I have felt active and energetic*

All of the time

Most of the time

More than half of the time

Less than half of the time

Some of the time

At no time

I woke up feeling fresh and rested*

All of the time

Most of the time

More than half of the time

Less than half of the time

Some of the time

At no time

My daily life has been filled with things that interest me*

All of the time

Most of the time

More than half of the time

Less than half of the time

Some of the time

At no time

Parenting

I take good care of my children even when I have personal problems*

In my family, we take time to listen to each other.*

I help my children calm down when they are upset.*

I am happy when I am with my children*

What is YOUR age?*

What is your ethnicity?

What is your race?

More than one race

Decline to answer

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Other

What language do you most often speak at home?

select one

What is your gender identity?

Man , Woman, Transgender man, Transgender woman, Non-binary, Undecided, Not Sure what the question means, Decline to Answer...

What sex were you assigned at birth?

Do you have any of the following disabilities?*

No Disabilities

Mental Disability

Physical/Mobility Disability

Chronic Health Condition

Hearing Difficulties

Seeing Difficulties

Another Communication disability

Another type of disability

Decline to Answer

Disability is defined as a mental or physical impairment lasting more than 6 months and limiting major life activitiy but is not the result of a severe mental illness.

I think of myself as

Heterosexual/Straight

Gay or Lesbian

Bisexual or Pansexual

Something Else

I don't know what this question means

Decline to Answer

Are you a veteran?*

Yes

Liability Waiver and Release

Waiver, Release, Assumption of Risk.*

In consideration of the services 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 "H4HLA") provide, I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge H4HLA 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 causes of action that I (we) have or may have, whether past, present or future, whether known or unknown, whether anticipated or unanticipated, as detailed here:

Academic Evaluation
I hereby give permission for the school to release any and all confidential school records to H4HLA for purposes of assessment and evaluation for the betterment of my child’s academic and social success and the effectiveness of H4HLA after school program. I hereby give permission for my child to participate in activities or surveys designed to evaluate the effectiveness of H4HLA

Physical Activities
I am voluntarily allowing my child to participate in instruction offered during online classes or in person, during which they may receive information and instruction about a number of topics. I recognize that may include fitness or dance classes may require physical exertion that 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 prior to and regarding my child's participation in dance or fitness related instruction if they are in those classes. I warrant that I am aware of any medical condition that my child may have, which may affect their participation. I agree to fully disclose this information to H4HLA staff.

Assumption of Risk:
I understand that there is an assumed risk of injury in all after school activities.I hereby waive all claims against H4HLA 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 H4HLA free from any liability or responsibility for damages arising from any injuries to my child or property owned by my child.

By signing this release agreement & waiver of liability form I am giving my child permission to attend H4HLA academic after school Program. I have read the above agreement and understand fully the terms and conditions above. I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge H4HLA 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 causes of action that I (we) have or may have, whether past, present or future, whether known or unknown, whether anticipated or unanticipated.

I have read and understand fully the terms and conditions to which I have consented above.

Signature of Parent/Guardian*

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Lankershim Elementary

Enroll Now

STUDENT 2

Household Information

Survey Questions which are required, but anonymized.

WHO Wellbeing Survey

Parenting

Liability Waiver and Release

Change Language

Contact Us!

Lankershim Elementary

Enroll Now

STUDENT 2

Household Information

Survey Questions which are required, but anonymized.

WHO Wellbeing Survey

Parenting

Liability Waiver and Release

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Change Language

Contact Us!