MATCH Enrollment Form – Boyz 2 Men Development, Inc.

M.A.T.C.H. After School Program – Mentoring, Affirming, Teaching, Counseling, and Healing

Welcome to the enrollment form for the M.A.T.C.H. After School Program – Mentoring, Affirming, Teaching, Counseling, and Healing! This program is designed to help youth in grades 2nd–9th grow academically, emotionally, and socially through mentoring, tutoring, and group counseling. Please complete all sections of the form below. Your submission will be reviewed by our program staff, and we’ll follow up with next steps to confirm your child’s enrollment.

If you have any questions or need assistance, contact us at (706) 593-6737 or email Boyz2mendevelopment@gmail.com.

Step 1 of 10 - Registration & Enrollment Policies

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Registration and Enrollment Policies

Registration: The parent must complete the registration form and submit it with a $25 non-refundable registration fee per child to Boyz 2 Men Development, Inc. to cover t-shirts and bags.

Eligibility: Children who are enrolled in Muscogee County Public Schools or approved online public school in grades 2nd-9th may be registered for enrollment in the program at any time. The M.A.T.C.H. program is NOT a daycare. All program participants must be enrolled in school and will be expected to participate in their school's daily activities to remain in the program.

Enrollment:
1. Parents will be asked to sign the COVID 19 acknowledgement, liability waiver and application/enrollment form that must be completed and returned to Boyz 2 Men Development, Inc. before the child's first day of attendance.
2. With the exception of the $25 registration fee, there are no other fees associated with enrolling participants or for participants to remain in the program.
3. Children will be allowed to attend the program only after all forms have been completed and returned.

Registration Acknowledgement(Required)

I have read and understand the policies above and would like to register my child for enrollment in the program. I acknowledge that a $25 non-refundable registration fee is due.

Parent/Guardian Signature(Required)

Date(Required)

Signing Date

Parent/Guardian E-Mail Address(Required)

Please provide an email address we can use to contact you.

School(Required)

Name of the school your child attends

Enrollment Agreement

Please read and acknowledge each statement below.

Child's Name(Required)

Name of the child being enrolled

Attendance Schedule(Required)

Select your child's attendance schedule

Mon-Thur from 3:30pm-6:30pm on days that the MCSD is also open

Custom schedule (specify below)

Custom Days and Times(Required)

Specify the days and times your child will attend (during operating hours Mon-Thur 3:30pm-6:30pm)

By submitting this form, I understand and agree to the following:

The Program is open according to the official school calendar of the Muscogee County Public Schools, and is closed on Fridays, Saturdays and Sundays. The program operates Mon-Thurs from 3:30-6:30pm and children are expected to be picked up by 6:30pm.
I am responsible for a registration fee of $25.
I must maintain and update my current phone number on file so that I may be reached in the event of an emergency, illness, etc.
The Program staff and volunteers will assume full responsibility for my child from the time he/she arrives at the program until my child leaves the program according to the written instructions for departure.
If a medical emergency arises, the Program staff will first attempt to contact me. If I cannot be reached, the staff will contact the person(s) on my emergency list. If the emergency is such that immediate hospital attention is necessary, an ambulance or emergency vehicle may take my child to the nearest hospital.

Enrollment Agreement Acknowledgement(Required)

I agree to adhere to the stated policies and procedures of Boyz 2 Men Development's M.A.T.C.H. program and give my child permission to participate fully in this program. I understand that the M.A.T.C.H. program ONLY operates on days that the Muscogee County School District is open for students.

Parent/Guardian Signature(Required)

Date(Required)

Signing Date

Relationship to Child(Required)

Define your relationship to the child.

Child's Identification

Please provide information about the child being enrolled.

Child's Name(Required)

First Last

Date of Birth(Required)

Race/Ethnicity

Gender(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Child's School Information

Grade(Required)

School Name(Required)

Teacher's Name

Parent/Guardian 1

Primary parent or guardian information.

Full Name(Required)

Relationship to Child(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell/Home Phone(Required)

Employer

Department/Extension

Work Phone

Work Hours

Does the child reside with this parent/guardian?(Required)

Yes

Would you like to add another parent/guardian?(Required)

Yes

Parent/Guardian 2

Additional parent or guardian information.

Full Name

Relationship to Child

Address

Street Address Address Line 2 City State ZIP Code

Cell/Home Phone

Employer

Department/Extension

Work Phone

Work Hours

Does the child reside with this parent/guardian?

Yes

Protective Order Status

Is there a separation, divorce or custody problem/Protective Order of which the program staff should be aware?(Required)

Yes

If yes, please explain

Authorized Persons to Drop Off and Pick Up

Although any adult can drop the child off, the child will ONLY be released to the individuals listed below as AUTHORIZED persons. Authorized persons MUST be at least 18 years old.

Authorized Person 1

Full Name(Required)

Relationship to Child(Required)

Address

Street Address Address Line 2 City State ZIP Code

Cell/Home Phone(Required)

Work Phone

Employer

Department/Extension

Work Hours

Would you like to add another authorized person?(Required)

Yes

Authorized Person 2

Full Name

Relationship to Child

Address

Street Address Address Line 2 City State ZIP Code

Cell/Home Phone

Work Phone

Employer

Department/Extension

Work Hours

Would you like to add a third authorized person?

Yes

Authorized Person 3

Full Name

Relationship to Child

Address

Street Address Address Line 2 City State ZIP Code

Cell/Home Phone

Work Phone

Employer

Department/Extension

Work Hours

Emergency Contacts

These should be local people who may be notified in case of emergency or illness. Please note that being listed as an emergency contact does NOT authorize this person to pick up the child.

Emergency Contact 1

Full Name(Required)

Relationship to Child(Required)

Cell/Home Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Would you like to add another emergency contact?(Required)

Yes

Emergency Contact 2

Full Name

Relationship to Child

Cell/Home Phone

Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Would you like to add a third emergency contact?

Yes

Emergency Contact 3

Full Name

Relationship to Child

Cell/Home Phone

Address

Street Address Address Line 2 City State ZIP Code

Work Phone

Waiver & Release of Liability - M.A.T.C.H. Program

As a parent, guardian and/or participant in Boyz 2 Men Development, Inc.'s M.A.T.C.H. program, I do hereby freely, voluntarily, and without duress execute this Release under the following terms:

Release and Waiver: I do hereby release, hold harmless, and discharge Boyz 2 Men Development, Inc., its officers, volunteers and employees from any and all liability for injury to myself, my child(ren) and others under my guardianship, damage to my property, or death, whether or not such liability is based upon allegations of negligence while participating in Boyz 2 Men Development, Inc.’s M.A.T.C.H. program.
Transportation Release of Liability: I acknowledge that if any transportation is offered by Boyz2Men Development, Inc. for its M.A.T.C.H. program, it will be FREE and optional and that using the services, or declining it, will not affect the status of my child being accepted into the program. I also understand and acknowledge that should I choose to utilize any transportation services provided by Boyz 2 Men Development, Inc. or secured or contracted by Boyz2Men Development, Inc. to transport myself, my child(ren) or others under my guardianship for the purpose of the M.A.T.C.H program, that I accept the risks associated with utilizing said transportation services and thereby expressly and specifically assume the risk of injury or harm in the activities and release Boyz2Men Development, Inc. and any partnering transportation providers, from all liability for injury, illness, death, financial or property damage resulting from participating in or allowing my child(ren) and others in under my guardianship to be transported to (or from) M.A.T.C.H. program activities.
Medical Treatment: I expressly give Boyz2Men Development, Inc. consent to take my child(ren) and others under my guardianship, in my absence, to the nearest clinic or hospital or call for an ambulance, in the event that my child(ren) or others under my guardianship, need emergency medical care. I also do hereby release and forever discharge Boyz 2 Men Development, Inc. any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, or service directly rendered by Boy2Men Development, Inc. or indirectly by the emergency medical personnel that may provide care to my child(ren) and others under my guardianship as a direct result of being called or contacted by Boyz 2 Men Development, Inc.
Photographic Release: I do hereby grant and convey unto Boy2Men Development, Inc. all rights, title, and interest in any and all photographic images and video or audio recordings made by Boy2Men Development, Inc. during M.A.T.C.H. program activities with Boy2Men Development, Inc., including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
Personal Property: I understand that any or all personal property damaged or lost is not the responsibility of Boy2Men Development, Inc.
Other: I agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Georgia, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Georgia. I agree that, if any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

Waiver Acknowledgement(Required)

I have reviewed and fully understand this Waiver and Release of Liability as a prerequisite for my child(ren) and others under my guardianship, to participate in BoyzMen Development, Inc.’s M.A.T.C.H. Program or participate in any transportation services they may provide. I certify that by signing this waiver and release, I am agreeing to assume the risk of any injury that occurs from participating or allowing my child(ren) or others under my guardianship, to participate in the M.A.T.C.H. program and understand that even if myself or my child(ren) or others under my guardianship, are seriously hurt because the provider was negligent, I have signed away my right to file a personal injury lawsuit and seek damages.

Parent/Guardian Name (Please Print)(Required)

Parent/Guardian Signature(Required)

Date(Required)

Children Participating in M.A.T.C.H. Program

Please list all children under your guardianship that will be participating in the M.A.T.C.H program.

Child 1 Name

Child 2 Name

Child 3 Name

Child 4 Name

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Enrollment Form

M.A.T.C.H. After School Program Enrollment

Registration and Enrollment Policies

Enrollment Agreement

Child's Identification

Child's School Information

Parent/Guardian 1

Parent/Guardian 2

Protective Order Status

Authorized Persons to Drop Off and Pick Up

Authorized Person 1

Authorized Person 2

Authorized Person 3

Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Emergency Contact 3

Release of Child

Workshop Interests

Allergies & Medications

Physical Assessment & Health Form

Media Release Form

Travel Authorization

Waiver & Release of Liability - M.A.T.C.H. Program

Children Participating in M.A.T.C.H. Program

Making A Difference