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Step
1
of
3
33%
Child's Name
*
First
Last
Current School Attending
*
Current Grade
*
Parent/Guardian's Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Parent/Guardian's Email
*
Parent/Guardian/s Phone
*
Location Attending
*
I, the undersigned parent or legal guardian grant permission for my child or ward to participate in the XABop program.
I understand, acknowledge, and agree that: XABop will provide for reasonable supervision of students within its care and control.
While XABop has taken appropriate action to ensure that this activity is conducted in reasonable safe conditions, there are certain risks inherent. XABop does not carry coverage for student accident insurance. I understand that if my child should be injured, I will be responsible for medical expenses. I further understand that an employee or volunteer has no personal liability unless he or she has acted recklessly, or intentionally to injure my child.
If your child needs special medial supplies, i.e., an inhaler, diabetic equipment or an Epi-pen,
IT IS THE PARENT'S RESPONSIBILITY
to provide this equipment to the XABop instructor if you have not already done so.
Knowing the dangers, hazards and risks of such activities, and in consideration of being permitted to participate in the activity, I agree to assume all the risks and responsibilities surrounding my child's participation in the activity.
I understand and agree that XABop may not have medical personnel available at the location of the activity. I understand and agree that XABop is granted permission to authorize emergency medical treatment, if necessary. I understand and agree that XABop assumes no responsibility of any injure or damage that might arise out of or in connection with such authorized emergency medical treatment.
Signature of Parent or Legal Guardian
*
First
Last
Date
*
MM slash DD slash YYYY
Emergency Contact Number
*
Request to Withhold Information
Child's Full Legal Name
*
First
Last
My child CAN be included in XABop related materials, including but not limited to pictures, newsletters, events, friendship lists, activity and event programs, new releases, and all websites.
*
Yes
No
My child CAN be included in social media accounts associated with XABoop
*
Yes
No
My child CAN be included in XABop hosted media events, including video, photography and verbal interviews with radio, television, and print media (Fox, Valley New Live, WDAY, Forum/Pioneer, etc.)
*
Yes
No
Behavior Contract
XABop instructor will provide student with a non-verbal warning.
XABop instructor will provide student with a verbal warning
XABop instructor will ask the student to RESET.
What is a reset? A reset is an opportunity for students to take a break by being removed from the high stimulation of the current activity to regain control of their behavior choices
After two Resets within a XABop class, the instructor will notify parents of the problematic behavior choices at the completion of the class
If the child becomes violent or leaves the class without permission, the teacher will immediately notify the parents and the child will be removed from all further XABop classes within the six-week unit they are signed up for, with no financial refund.
In emergencies, teachers will call 911 first
I agree to the terms of the XABop Behavior Contract
Signature of Parent/Guardian
*
First
Last
Date
*
MM slash DD slash YYYY
Any additional medical info
Comments
This field is for validation purposes and should be left unchanged.
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