Out‐of‐School Time Programs RISE Summer Enrichment Registration Checklist 

Please review the information below regarding the registration requirements for our RISE Summer Enrichment program. If you have any questions, please feel free to contact Registration Management directly at OSTRegistration@vbgov.com.  

HOW TO REGISTER YOUR CHILD IN OUR RISE SUMMER ENRICHMENT PROGRAM 

1. Complete and sign the 2020 RISE Summer Enrichment Application o Every section must be completed and signed, if it is not applicable, indicate N/A 

2. Submit your completed application to OSTRegistration@vbgov.com subject line: 2020 Summer RISE Enrichment Application o Legal Documentation must be submitted with your application if indicating Legal Guardian o Your child’s Free and Reduced Lunch Letter if they do not have a current Parks & Recreation Reduced Fee Waiver 

3. OST Registration Management Staff will review your forms and documentation submitted to determine program eligibility 

4. Applications received that meet program eligibility requirements will receive instructions for registering on‐line 

REQUIRED FORMS AND DOCUMENTS 

□ 2020 RISE SUMMER ENRICHMENT APPLICATION COMPLETED  All sections on each page are completed and signed by a parent/legal guardian  At least 2 adults, other than a parent are indicated as Emergency Contacts & Authorized to Pick‐Up 

□ LEGAL DOCUMENTATION FOR LEGAL GUARDIANS OR PERSON NOT‐AUTHORIZED TO PICK‐UP INDICATED  Current Custody Order from the Courts or Notarized Power of Attorney 

Note – Notarized Power of Attorney must indicate the legal guardian has the right to perform parental acts such as registering for daycare and/or school. A Medical Power of Attorney is not acceptable for proof of guardianship. 

□ FREE AND REDUCED LUNCH LETTER FROM VIRGINIA BEACH CITY PUBLIC SCHOOLS FOOD SERVICES OFFICE  Indicates “Free” or “Reduced” lunch for the 2019/20 School Year 

Will your child require medication to be administered during camp? If yes: 

□ MEDICATION Consent Form  All required sections are accurately complete and an Authorized Licensed Prescriber has signed  Submit our form at least 2 weeks prior to beginning 

Note – Please review our form to ensure all sections are accurately completed. Incomplete and/or outdated forms will delay the approval process. 

Will your child require an epinephrine injection during camp? If yes: 

□ CONSENT AND RELEASE OF EPINEPHRINE FORM  All required sections are accurately complete and an Authorized Licensed Prescriber has signed  Medication Consent Form is accurately completed and submitted with this form at least 2 weeks prior to beginning 

Note – Please review our form to ensure all sections are accurately completed. Incomplete and/or outdated forms will delay the approval process. 

Does your child require an accommodation? If yes, the form below is required 

□ INCLUSION, ACCOMMODATION & SPECIAL NEEDS REQUEST FORM  Complete the appropriate form on‐line at www.vbgov.com/inclusion  E‐mail completed form to princlusionservices@vbgov.com 

Note – Accommodations do not automatically transfer. An Inclusion Specialist will contact you once they have received your request.   

Would you like to have your balance set up on autopay? If yes: 

□ AUTHORIZATION FOR AUTOMATIC PAYMENTS FORM PROVIDED  Submit at least 5 business days prior to the payment due date 

Note – Automatic Payments do not transfer between programs. A new form is required for each registration period. 

 

Out-of-School Time Program RISE 2020 Summer Enrichment Program Application All sections of this form must be completed and submitted with payment. If the Release of Virginia Beach City Public Schools Student Information section is incomplete: original birth certificate, school entrance immunization and physical records must be submitted prior to attending.

PARTICIPANT INFORMATION Complete all fields below. One form per participant is required.

Name Address City & Zip

Primary Phone Female Male Date of Birth Age

Nickname Grade (2019-20 school year) Previous Daycare/School

Physician’s Name & Practice Phone

Allergies to food, medicines, etc.

Will participant require medication to be administered during the program? NO YES A MEDICATION CONSENT FORM IS REQUIRED

Does participant have special needs (developmental, emotional, physical) that require accommodations? NO YES AN ACCOMMODATION FORM IS REQUIRED

Has participant had an Accommodation Plan with us in the past? NO YES PLEASE PROVIDE DATES:

PARENT/LEGAL GUARDIAN INFORMATION Complete all fields below. Legal Documentation is required at registration and does not stay on file for Legal Guardians. Relationship to participant: Parent Step-Parent Legal Guardian Legal Documentation required

Name Address City & Zip

Email (REQUIRED)

Primary Phone

Home Cell

Secondary Phone

Work Cell

Cell Provider

Female Male Date of Birth Employer

Relationship to participant: Parent Step-Parent Legal Guardian Legal Documentation required

Name Address City & Zip

Email (REQUIRED)

Primary Phone

Home Cell

Secondary Phone

Work Cell

Cell Provider

Female Male Date of Birth Employer

EMERGENCY CONTACT & AUTHORIZED TO PICK UP INFORMATION COMPLETE ALL FIELDS BELOW FOR EACH ADULT OTHER THAN THE PARENTS ABOVE; MINORS CANNOT BE INDICATED.

Name Address City & Zip

Primary Phone

Home Cell

Secondary Phone

Work Cell

Relationship to Participant

Name Address City & Zip

Primary Phone

Home Cell

Secondary Phone

Work Cell

Relationship to Participant

Name Address City & Zip

Primary Phone

Home Cell

Secondary Phone

Work Cell

Relationship to Participant

Name Address City & Zip

Primary Phone

Home Cell

Secondary Phone

Work Cell

Relationship to Participant

PERSON(S) NOT-AUTHORIZED TO PICK UP Non-Custodial parent(s) shall be allowed to pick up unless a court order prohibiting such release or terminating parental rights is

submitted with your child’s registration form. Documentation does not stay on file and is required for each program registration period if indicating a biological or step-parent below.

Name(s)

Relationship to Participant

REVISED 5 /2020

INDICATE THE RISE SUMMER PROGRAM LOCATION WITH A ✓ BASED ON THE PARTICIPANT’S CURRENT GRADE (19/20 SCHOOL YEAR)

Current Grade: Kindergarten & 1st Current Grade: 2nd & 3rd Current Grade: 4th & 5th

Diamond Springs Brookwood Newtown Brookwood B.F. Williams Brookwood

I understand that RISE is a nine-week summer education enrichment program. My child will participate in all academic and recreational activities each day. I will notify the Out-of-School Time Programs, Registration Management in writing prior to the program beginning of any dates that may conflict with the attendance requirement. I understand that failure to do so may result in removal from the program and/or elements of this program.

Parent/Legal Guardian Signature: Printed Name: Date:

RELEASE OF VIRGINIA BEACH CITY PUBLIC SCHOOLS STUDENT INFORMATION (Complete below; if declined must provide Birth Certificate, School Entrance Immunization and Physical Records)

FERPA Authorization: I hereby authorize the School Board and School Administration for Virginia Beach City Public Schools to release and/or discuss non-directory and related information regarding the student named on this registration form to: City of Virginia Beach Department of Parks & Recreation Staff, Out-of-School Time Programs, 2154 Landstown Road, Virginia Beach, VA 23456 (Phone: 757-385-0402).

The purpose of releasing this information is: to obtain information relevant to the student’s birth certificate, custody and visitation arrangements, inoculation or related health records and emergency contact information. I affirm that I have read carefully the foregoing authorization and that I fully understand the meaning and intent of this release. I affirm that I have signed this authorization voluntarily, and knowingly and with the intent of being legally bound. I also understand that I may revoke any part or all of this authorization at any time upon submission of an updated FERPA Authorization Release to the school that the student attends.

For participants in RISE Programs at Title I Schools who apply for a reduced fee: I hereby give permission to the School Board and School Administration of the Virginia Beach City Public Schools to release to Virginia Beach Parks and Recreation information concerning eligibility for Free and Reduced Lunch under the National School Lunch Act for the participant listed below. This information may be released for the sole purpose of determining eligibility for participation in or reduction of participation fees in the RISE Program. This information may not be used for any other purpose and may not be shared with persons not directly related to the program for which the student’s are applying.

Student’s Name School Attends

Parent/Legal Guardian Signature Parent/Legal Guardian Printed Name

PROGRAM INFORMATION AND EXPECTATIONS OF ALL PARTICIPANTS complete all fields below To ensure an understanding and acknowledgement please check off each box and sign below:

Staff will attempt to notify me whenever my child becomes ill, has behavior issues, or in situations of emergency or inclement weather. I will arrange to have my child picked up within the hour of receiving the phone call.

If my child or someone in my household comes down with a reportable communicable disease, I will notify OST staff within 24 hours so they cannotify the parents of other program/camp participants and local health authorities (all names will remain confidential).

An emergency operations plan has been developed to help staff and participants be prepared for situations. This is posted at all sites, updatedannually and a copy of the plan can be provided upon request.

I authorize emergency personnel to treat my child in case of an emergency. I understand that staff will keep me updated on my child’s behavior. If I do not pick up my child, I release staff to share behavioral information to the

approved individual on my pick-up list. If my child is enrolled in a licensed program, I will be provided written summaries on my child’s behavior at least twice a year. I am responsible for reviewing contents of the Parent Handbook and complying with its contents. I will provide my child’s proof of identity (Birth Certificate, Passport) and immunization record if they are enrolled in a licensed program and/or they

are not enrolled in the Virginia Beach City Public Schools.

Parent/Legal Guardian Signature Date

ASSUMPTION OF RISK AND POLICIES & PROCEDURES must be completed; if declined/incomplete will not be able to register/attend

I, for myself and/or child named here as a patron and/or participant in a Virginia Beach Parks & Recreation Facility and/or Program/Camp, am aware of the possibility of accidental or other physical injury which may befall me or my child(ren) during my/our use of the facility, equipment, and/or participation in Programs/Camps conducted by this department including Programs/Camps co-sponsored with other agencies. I do hereby assume the risks of possible accidental injuries that I or my child(ren) may suffer while utilizing Virginia Beach Parks & Recreation Facilities and/or Programs/Camps and release from any and all liability of cause of action, the City of Virginia Beach, its employees, agents and volunteers. I agree to follow all the policies and procedures in the Parent Handbook. I hereby provide my consent for the Department of Parks and Recreation to use photographs, videos and/or interviews with me and/or my child(ren) in connection with publicizing or promoting the City of Virginia Beach, its services, or departments and agencies. I understand that there will be no remuneration for such use.

Parent/Legal Guardian Signature: Printed Name: Date

Office Use Only

Received By & Date Document Type: Birth Certificate Birth Record Passport

Document/Passport # Date Issued Date Expires

Date of Birth Place of Birth

Program Start Date Program End Date

Comments

Out-of-School Time Programs Medication Policy

We have strict guidelines for approving medications your child may require while in our programs. Our Medication Consent Form(s) are required to be submitted for each medication your child may require while in our programs, each registration period. Please note that approval may take up to two weeks, depending on when your forms are submitted and received. Incomplete and/or out dated forms will delay the approval process.

Our Medication Manager will contact you with further instructions relating to the medication process once we have received your child’s medication forms. Until this occurs, we are unable to accept medication(s) that have not been approved by our Medication Manager. If you have any questions regarding medications, please call 757.385.0431.

Procedure for Self-Administered Medication/Equipment

• All medication will be self-administered, except an Epinephrine Injector unless the Permission to Carry and/or Self-Administer Life Saving Medication is approved

• Out-of-School Time Program Staff will:

• Lock up the medication or equipment unless the Permission to Carry and/or Self-Administer Life Saving Medication is approved

• Contact parent immediately if any problem arises concerning this medication or equipment

• Not be responsible for equipment if broken

• Discuss any concerns with the medication or specialized procedures request with the parent/legal guardian

• Accommodations will be made as necessary

• Any changes in the medication, dosage and/or specialized procedure require a new Medication Consent Form to be submitted for approval before medication can be brought to the program or specialized procedure be implemented

• Approved medication must be provided to the Out-of-School Time Program staff within 30 days of being notified of the approval. If the requested medication is not provided to program staff within 30 days of approval, the form will become null and void and the parent will be required to resubmit the form for approval if the need for medication in the program still exists

Medication

Parents will:

• Make alternate arrangements for administration of any medication that cannot be self-administered prior to submitting completed medication consent forms

• Educate their child in regards to the medication administration requirements

• Provide approved medications in the original pharmacy/physician labeled containers and appropriate administration tools to measure the dose accurately (i.e. measuring cup, spoon, etc.)

• Verify the amount of medication being dropped off with Out-of-School Time Program staff

• Verify any unused medication with staff on the participant’s last day for each week and staff will return the unused medication to the parent

• “As Needed” medications such as Inhalers, Benadryl, Epinephrine Injectors will be maintained at the site for the duration of the program in which the participant is enrolled if requested by the parent

• Parents are encouraged to meet with the Out-of-School Time Program staff to review their child’s medication needs periodically

• At the time specified in the frequency section herein, the Out-of-School Time Program staff will hand the medication to the participant and someone from the Out-of-School Time Program staff will oversee the taking of the medication by checking visually under the participant’s tongue/mouth if the medication is taken orally

• The Out-of-School Time Program staff will document that medication was self-administered on a medication log which will be submitted to the OST Medication Manager bi-weekly

• Any unusual side effects will be reported immediately to the parent and OST Medication Manager, if severe, 911 will be called

Specialized Procedure

• A Release for the Administration of Epinephrine Injections Form must be completed and signed by a physician and parent in addition to this form in order for a participant to carry an Epinephrine Injector or the site to maintain an Epinephrine Injector for a participant

• Parent understands and acknowledges that with the exception of the Epinephrine Injection, Out-of-School Time Program staff are not trained to administer medication and do not have legal authority to do so

OUT-OF-SCHOOL TIME PROGRAMS MEDICATION CONSENT FORM Please ensure all sections of this form is completed accurately and fully. Incomplete and/or out dated forms will delay the approval process. One form is required per medication, per program registration period.

1) Parent/Legal Guardian MUST complete #1-#7 and #15. #8-#14 MUST be completed for medication to be administered 10 days or less, non-prescription or topical medications, or submitting alternate consent forms such as Hampton Roads School Medication, Life Threatening Allergy Management Plan (LAMP) or Virginia Asthma Action Plan.

2) Licensed Authorized Prescriber MUST complete #8-#14, #17 (if applicable) and #18-#21

3) If your child requires an Epinephrine Injector, you MUST complete this form AND our Consent for the Administration of Epinephrine Injections Form

4) Submit completed forms at least 2-weeks before your child will begin. The Medication Manager will contact you once they have received and approved your forms.

PARENT/LEGAL GUARDIAN INFORMATION

1. FIRST & LAST NAME 2. PRIMARY PHONE 3. DATE COMPLETED

PARTICIPANT INFORMATION

4. FIRST & LAST NAME 5. DATE OF BIRTH 6. PROGRAM (CHECK ONE)

□ SCHOOL YEAR □ SUMMER

7. ALLERGIES

MEDICATION INFORMATION

8. NAME OF MEDICATION INCLUDING STRENGTH 9. AMOUNT/DOSAGE TO BE GIVEN 10. ROUTE OF ADMINISTRATION

11. FREQUENCY TO ADMINISTER OR SPECIFIC TIME 12. IDENTIFY SYMPTOMS THAT WILL NECESSITATE ADMINISTRATION

13. POSSIBLE SIDE EFFECTS (PARENT MUST SUPPLY PACKAGE INSERT) 14. DATE TO BE DISCONTINUED OR LENGTH OF TIME IN DAYS TO BE GIVEN (CANNOT EXCEED 12 MONTHS)

PARENT ACKNOWLEDGMENT AND RELEASE

I will not hold the City of Virginia Beach, Virginia Beach Department of Parks and Recreation and its, Out-of-School Time Programs unit or any of its employees, contractors or agents liable for any negative outcome resulting from the self-administration of medication approved on this form by the participant.

I understand that the Virginia Beach Department of Parks and Recreation, Out-of-School Time Programs unit, after consultation with the parent(s) may impose reasonable limitations or restrictions upon a participant’s possession and/or self-administration of said medication relative to the age and maturity of the participant and other relevant consideration.

I understand that the Virginia Beach Department of Parks and Recreation, Out-of-School Time Programs unit, may withdraw permission to carry and self-administer medication at any point during the duration of the program if it is determined the participant has abused the privilege of carrying and self-administration or that the participant is not safely and effectively administering the medication.

I have read and fully understand the procedures and guidelines set forth in the Out-of-School Time Programs Medication Policy.

I have read and fully understand these guidelines. I voluntarily consent to the program maintaining the medication listed herein and to my child self-administering said medication(s). I further agree to adhere to the above guidelines.

15. PARENT/LEGAL GUARDIAN SIGNATURE DATE

16. PARTICIPANT SIGNATURE (FOR SELF-CARRY AND/OR SELF-ADMINISTER REQUEST) DATE

LICENSED AUTHORIZED PRESCRIBER INFORMATION

17. PERMISSION TO CARRY AND/OR SELF-ADMINISTER LIFE SAVING MEDICATION

This section is to be completed if a participant has a life-threatening medical condition and the healthcare provider, parent and participant agree the participant is mature and able to carry the medication and/or self-administer as needed.

Licensed Prescriber please check all that apply:

□ I as the Healthcare Provider, certify that this child has a medical history of asthma and has been trained in the use of the prescribed medication(s). Staff on Duty and an OST Supervisor should be notified anytime the medication is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice.

□ I as the Healthcare Provider, certify that this child has a medical history of severe allergic reactions and has been trained in the use of the Epi-Pen. Staff on Duty and an OST Supervisor should be notified anytime the injector is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice.

□ Self-Carry □ Self-Administer

18. LICENSED PRESCRIBERS PRINTED NAME 19. LICENSED PRESCRIBERS SIGNATURE 20. LICENSED PRESCRIBERS TELEPHONE 21. DATE AUTHORIZED

OUT-OF-SCHOOL TIME PROGRAM MEDICATION MANAGER INFORMATION

22. DATE RECEIVED 23. DATE PROCESSED 24. PROGRAM NAME & LOCATION

25. DECISION

□ APPROVED □ PENDING □ DENIED

26. REASON (IF PENDING/DENIED INDICATED)

27. PARENT CONTACTED (DATE, TIME, METHOD) 28. DATE ENTERED INTO MEDICATION SPREADSHEET 29. DATE MEDICATION LOG CREATED

30. MEDICATION MANAGER PRINTED NAME 31. MEDICATION MANAGER SIGNATURE

Revised 3/17/2020

CONSENT AND RELEASE FOR THE ADMINISTRATION OF EPINEPHRINE INJECTIONS Please ensure all sections of our forms are completed fully and accurately. Incomplete and/or out dated forms will delay the approval process. One form is required per medication, per program registration period.

1) Parent/Legal Guardian MUST complete #1-#6

2) Licensed Authorized Prescriber MUST complete #7-#10

3) Our Medication Consent Form MUST be completed and submitted with this form at least 2-weeks before your child will begin attending. The Medication Manager will contact you once they have received and approved your forms.

PARENT/LEGAL GUARDIAN INFORMATION 1. FIRST & LAST NAME 2. PRIMARY PHONE 3. DATE COMPLETED

PARTICIPANT INFORMATION 4. FIRST & LAST NAME 5. DATE OF BIRTH

Epinephrine injections may be given during the Out-of-School Time programs only with a physician and parent/legal guardian written authorization on this form and the Parks and Recreation Out-of-School Time Medication Consent Form.

Virginia Beach Department of Parks and Recreation, Out-of-School Time program staff will not administer Epinephrine unless it is a life-threatening situation and the participant is unable to self-administer the injection.

Unless the participant has been approved by the Out-of-School Time program Medication Manager and his/her treating Physician to self-carry, you must provide the epinephrine injector to the Out-of-School Time program staff within 30 days of being notified of the approval. If the requested medication is not provided to the Out-of-School Time program staff within 30 days of approval, the form will become null and void and the parent will be required to resubmit the form for approval.

I acknowledge and understand that there may be certain side effects and risks associated with the administration of an Epinephrine Injection. Accordingly, as the parent/guardian of the participant, for yourself, your child and your heirs, waiver, release, and forever discharge the City of Virginia Beach, and its agents, employees, volunteers, representatives and officials of and from any and every claim, demand, action or right of action, of whatsoever kind of nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, or death resulting on account of the Epinephrine Injection administered to the participant while participating in the program.

This consent and release shall be governed by the laws of the Commonwealth of Virginia and agree to venue in the Virginia Beach Circuit Court as to all disputes arising from this consent and release. If any provision of this consent and release is held to be invalid by a court of competent jurisdiction, the remainder shall, notwithstanding, continue in full legal force and effect.

I have read and understood the provisions of this consent and release, and by signing this form, I agree to abide and be bound by all its terms and conditions.

6. PARENT/LEGAL GUARDIAN SIGNATURE DATE

LICENSED AUTHORIZED PRESCRIBER INFORMATION 7. LICENSED PRESCRIBERS PRINTED NAME 8. LICENSED PRESCRIBERS SIGNATURE 9. LICENSED PRESCRIBERS TELEPHONE 10. DATE AUTHORIZED

OUT-OF-SCHOOL TIME PROGRAM MEDICATION MANAGER INFORMATION 11. DATE RECEIVED 12. DATE PROCESSED 13. MEDICATION CONSENT FORM RECEIVED

□ YES □ NO

14. PROGRAM NAME & LOCATION 15. PARENT CONTACTED (DATE, TIME, METHOD)

16. ADDITIONAL NOTES

17. MEDICATION MANAGER PRINTED NAME 18. MEDICATION MANAGER SIGNATURE

Revised 2/25/2020