Youth Participant Application June 11, 2018 to August 17, 2018 “We are reaching a community, equipping a generation and empowering individuals” India House is a legacy for the next generation. A key to building legacy is through education. India House has successfully opened its doors; the organization is pursuing its vision of serving as a “window to the past and a door to the future.” India House provides support services for those who are socio-economically disadvantaged and offers cultural activities to Showcase Indian culture to the Greater Houston community. Cultural and artistic opportunities abound at India House. Visitors can choose to participate in Bollywood Dance classes, Yoga exercises, medical and legal seminars and a Library. Taped Ball Cricket camp for youth and tournaments for adults are held on a fully laid out cricket pitch. The multicultural setting is certain to foster a better understanding of all races and places.

Youth Coordinator 713-929-1900 [email protected]

Page 1

Student’s Information Name: ___________________________________Date of Birth: _____ /_____ /_____ Gender: M___F___ Grade_______ Current School: __________________________________ Parent’s Information First Name __________________ MI____ Address

______________________________________________________________________________

City _________State ________ Zip Driver’s License / State ID # Phone (Cell)

Last Name __________________

__________

E-mail ________++++++++++++_____________________

_______________________

State of Issue

__________________________

______________________ (Hm) _______________________ (Wk) _______________________

Ethnicity: Asian Black Hispanic White/ Anglo Other

Marital Status (M, S, D, W)

***India House must obtain verifiable certification(s) form the assisted person that his/her family income does not exceed the applicable income limit (24CFR 570.506 (b)). Total Monthly Household Income______________________ Total Members at home: Adults ______Kids______ Emergency Contact Information Contact #1: Name

_________________________________Phone Number __________________________

Contact #2: Name

_________________________________Phone Number __________________________

Please introduce your child or yourself to us with any special comments; for example, medical conditions or custody issues. Additionally please add any others person that is allowed to pick up your child: ___________________________________________________________________________________________ ___________________________________________________________________________________________

Fees & Schedule: One-time Application fee $35.00 per student & Weekly Fee- $10.00 per student payable on the previous Friday or on Monday Snack will be provided daily Hours - 3pm to 6pm Monday through Friday (We follow the HISD holiday schedule)

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Consent & Liability Waiver 1. I, the participant or parent/guardian, certify full approval for me or my child(ren) participation in the India House Programs: After-school program conducted at India House, 8888 West Bellfort, Houston TX 77031. 2. I hereby acknowledge that participation in the after school program, may include various physical activities that may expose me or my child(ren) to the risk of bodily injury. I hereby authorize India House to administer emergency care or first-aid. I further authorize medical treatment; including, but not limited to emergency surgery and assume financial responsibility for all expenses incurred for such treatment. 3. I further acknowledge that India House Houston is not liable for any injury sustained related to programs held at its facility and hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation at India House Houston. I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of negligent, willful or intentional acts of the participant. By signing this document, I certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions. I also assume all risks and waive and release certain substantial rights that I may have or possess against India House Houston or any of the covered parties.

Personal Consent, Release and Waiver form Child’s/Participant’s Name: ______________________________________________________________ Age: ________________________ Grade: __________________________ DOB: __________________ Phone Number_________________________________________________________________________ Parent’s Name (please print): ____________________________________________________________ Parent’s Signature: ____________________________________________________ Date ____________

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Medical Affidavit Date:

________________ Referring Physician:

Name:

____________________________________________________ Date of Birth: _____ /_____ /_____

SS#:

__________________________________________________________________________________

Gender:

Male

Address:

__________________________________________________________________________________

City:

________________________________________ State: _________________ Zip: _______________

Telephone

(Cell)

_____________________________________________

Female

_______________________________ (Home) ________________________________

(Work) ________________________________________________________________________

HMO:

____________________ PPO_________________________ Medicaid ________________________

Insurance Company Information Insurance Name:

__________________________________________________________________

Subscriber’s Name:

_________________________________________ Sex: ________ DOB: _______

SS#:

_________________________ Relationship:

Insurance ID#:

_____________

________________________

Group #:

_________________________

Other Insurance Information: _________________________________________________ Emergency Contact Name:

_________________________________________________

Emergency Contact Phone #:

_________________________________________________

CONSENT FOR TREATMENT: I hereby agree and give consent for medical treatment

Parent/Guardian or Participant’s Signature: ________________________ Date: ________________

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Discipline Policy and Protocol India House strives to provide all children with a safe, secure and healthy environment when they are in our care. Each child will have the opportunity to review the rules and regulations of this facility as well as the clear set rules pertaining to their specific classroom. Children will be reminded daily of expectations, rules, and boundaries. In the event that a child continues to display unacceptable behavior, India House will initiate the below mentioned Discipline Protocol.

Verbal Warning

1st Offense

Written Warning/ Notify Parents 2nd Offense

Suspension or Expulsion

3rd Offense

Please note that each misbehavior is evaluated by the Youth Coordinator. Depending on the severity or seriousness of the matter, one could be suspended or expelled immediately. This decision is solely based on the discretion of the Youth Coordinator. Each issue will be handled on a case by case basis. We want each of our children to feel safe and secure here at India House. We strive to be a Haven for the children in our care.

By signing below you acknowledge that you have read the above information and fully comprehend.

_______________________________________

_______________________

Parent/Guardian

DATE

_______________________________________

_______________________

Child

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Rules and Regulations 1. Parents must sign students in and out of the program “DAILY”. Child(ren) may not sign his/herself in or out. 2. Fighting and/or offensive language towards program staff, volunteers, or students will not be tolerated. Behavioral issues will be handled with a write up and if deemed necessary the parent will be contacted for pick up immediately. View Discipline policy for process of handling behavioral/misconduct issues. 3. No cell phones, MP3, IPods, tablets, or handheld games are allowed during classroom instruction and activities. If these items are misused, they will be confiscated and the PARENT must collect them from the Youth Coordinator. 4. If children are not picked up by program end time then you will be assessed a late fee of $10 plus an additional $10 per hour. These charges must be paid prior to your child returning to the program. Any child that has not been picked up within one hour of program end without proper communication will be considered abandoned and reported to proper authorities. 5. Children are not allowed to leave India House property without proper written consent from parent or individual authorized to pick up youth per registration form. 6. Pick up persons identified on emergency information form will be the only people validated to pick up/sign out children besides parents. Anyone not identified on the pick-up list will need to be validated with a written note upon morning drop off to India House Youth Program Staff. Pick-up persons MUST present a valid ID upon arrival. Children will NOT be released from India House without proper notification, a written note, or a validated pick –up person. 7. Payments must be made prior to the week of service. If payment is not made accordingly then your child may not return to the program until payment is made. Payments may be made by cash or credit card only. 8. Attendance is very important and has a direct link to the effectiveness of our program. Three consecutive unexcused absences may result in your child being dropped from the program, in order to allow another child to attend who may be on the waiting list. 9. Children must abide by the dress code or parents will be asked to take child home to change in order to participate for the remainder of the day. 10. Food Program is provided for all participants. Children must eat what is provided by the food program. Please read this form and sign to acknowledge that you have read and understand the rules and regulations for this program.

Parent Print ______________________________________________________ Parent Signature__________________________

Date_________________

Student Signature

Date __________________

______________________

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DRESS CODE PERSONNEL PROCEDURE (Coordinator, Teachers, Children and Sponsors) SECTION: Standards of Conduct SUBJECT: Procedure Dress and Personal Appearance REFERENCE: Policy Dress and Personal Appearance To promote a positive and professional image on behalf of the Company, employees and students will use good judgment and reasonable discretion in their choice of appropriate attire and personal hygiene practices. Employees will maintain an appropriate appearance that is professional, neat and clean as determined by the requirements of the area in which the employee works. I. Appropriate attire includes clothing that is clean, appropriate for the work or activity to be performed, and worn according to the design intent of the garment. Including the following:    

A Shirt or blouse that covers the midriff and back when sitting, standing, bending or stretching; A skirt, dress or shorts no more than 2 inches above the knee; Full-length pants or slacks, not so long as to cause a tripping hazard; Shoes of a safe and practical height, appropriate for the work or activity to be performed

II. Inappropriate attire includes:      

Stirrups, spandex, or any other pants that are not full length or inappropriately tight-fitting or baggy; Halter tops without covering Work-out clothes, sweat suits Sunglasses (worn indoors as a fashion accessory) Undergarments which are inappropriately obvious Clothing that is revealing or provocative

III. Good personal hygiene includes:  

Hair that is clean, neat and trimmed, including sideburns, beards, and mustaches Personal cleanliness.

IV. Good personal hygiene does not include:   

Excessive perfume or cologne Excessively long finger nails Excessive jewelry and accessories that detract from a professional image

Page 7

Urban Youth Summer Camp Application 2018.pdf

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