After School Application – Kent/Sussex County

Do you meet the eligibility requirements? If not, please explain.

Why would you like to attend this program?

This program is funded by the Division of Vocational Rehabilitation, and students applying to the school must have some form of disability to be considered. You will be required to supply documentation of your disability such as an IEP, 504 Plan, Axis I-IV Diagnosis or documentation from a Doctor. What is your disability?:

I hereby affirm that my answers to the foregoing questions are true and correct and that I have not withheld any fact or circumstances that would, if discovered, affect my application unfavorably. I understand that the misrepresentation of omission of a fact called for in this application or any other school records will be cause for immediate dismissal. In addition, I authorize Humanity's Kitchen to verify any and all information contained in this application. I hereby release Humanity's Kitchen from any liability whatever that may arise by such disclosure or investigation. I understand further that, should any falsification be discovered, it will constitute cause for non-acceptance or dismissal. I understand that I can make a written inquiry, within a reasonable time, for a complete and actual disclosure of the contents and scope of the information requested. I agree in the event of my training, to complete and abide by all the company's rules and regulations. Any misrepresentation made in this application will be sufficient cause for cancellation of this application and/or separation of training. This application for training shall be considered active for a period of time not to exceed 60 days. At the conclusion of this time, if I have not heard from HK and still wish to be considered for training, it will be necessary to fill out a new application. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any training relationship with HK is an "at will" nature, which means that the trainee may resign at any time and HK may discharge the trainee at any time with or without cause. It is further understood that this "at will" training relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I hereby release Humanity's Kitchen from any liability resulting from accident or injury occurring as a result of my participation in the culinary training program.

Youth's Name

CONCERNS & SPECIAL NEEDS: Please explain and "yes" answers, noting the number of the question. Also, indicate and activities your youth WOULD NOT be able to participate in while at camp and/or any other health issues we should be aware of."

The following information is important for the safety and protection of your child. Please read this information and sign below.

• I understand that HK is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

I have read and understand the statements above regarding HK policies and procedures.

At HK we take the happiness of your children very seriously. We want every day here to become a happy memory for them. Therefore, we work hard at creating an environment that will allow this to happen. Along with our efforts, we need the children to help us create that environment by following some simple, but effective rules. Below is our Behavior Agreement, please read over it with your child and be sure they understand what it is and why they are signing it. This will help us help them have a wonderful experience at HK Culinary Summer Camp! Thank you!

Not abiding by these rules can result in suspension from the program. All incidents will be handled on a 3 incident system, except hitting/fighting. Hitting/fighting will be an immediate 1-day suspension from the program. All other incidents will be handled as follows:
1st Incident: Verbal Warning 2nd Incident: Written Warning Parent Meeting 3rd Incident- 1-Day Suspension

I expressly acknowledge that there are certain dangers, risks, illnesses and personal injuries inherent in participating in the HK's programs, events, classes, and/or other activities, which may result from unavoidable accidents or injuries, classes, the use of any equipment, or other activities or from my or my minor child(ren)'s or ward(s)'' physical condition. I understand that HK and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns assume no responsibility for loss, damage, illness or injury to person or property that I or my minor child(ren) or ward(s), if applicable, may sustain as a result of my or their physical condition or resulting from my or their participation in any activities, programs, events, classes, the use or non-use of any equipment, field trips, or any other activities, classes, events, or programs at and/or sponsored by HK. I expressly acknowledge, on behalf of myself and my minor child(ren) and ward(s), heirs and executors, that I voluntarily assume the sole risk for any and all dangers, illnesses and personal injuries that may result from my or my minor child(ren)'s or ward(s)' participation in any events/activities/programs/classes while at HK and/or sponsored by HK.

I also acknowledge that HK often uses photographs, videotapes, television programs, motion pictures, tape recordings, or other similar media for promotional purposes. I hereby consent to the use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es) in such materials to be exhibited and used for advertising, trade purposes, solicitation of patronage, promotional purposes, or other similar purposes, even if my and/or my minor child(ren)'s or ward(s)'' name(s) and/or likeness(es) are an integral part of such photograph, videotape, television program, motion picture, tape recording, or other similar media. I hereby release Humanity's Kitchen from any and all claims, actions, and liability relating to its use of said photographs and/or videos.

In consideration of HK allowing me and/or my minor child(ren) or ward(s) to attend and/or participate in any programs, events, classes, or other activities at HK and/or sponsored by HK, I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge HK and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all rights and claims for any loss, damage, illness or injuries to person or property sustained as a result of my attendance and/or participation in any such programs, events, classes, and other activities, whether or not such loss, damage or injury results from the negligence of HK and its employees, agents, or representatives or from some other cause. My agreement to release HK does not include any loss, damage or injury that results from the HK's gross negligence or willful, wanton, or reckless misconduct.

I further waive any and all rights to inspect or approve the photograph, videotape, television program, motion picture, tape recording or other use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es), including any written article, script, caption or other writing that may accompany such use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es). I hereby, for myself, my minor child(ren) or ward(s), heirs, and executors, waive, release and forever discharge HK and its employees, agents, counselors, teachers, trainers, representatives, successors and assigns, from and against any and all liability, claims, losses, costs, expenses or damages for libel, slander, invasion of privacy, conversion, defamation, appropriation of likeness or any other claim based on the use of my and/or my minor child(ren)'s or ward(s)' name(s) and/or likeness(es) in any such materials.

I hereby represent and warrant to HK that I have the authority to execute this Participant Waiver Form on behalf of myself and/or on behalf of my minor child(ren) or ward(s) as parent, guardian and/or next friend, if applicable. In the event of any misrepresentation or breach of the foregoing warranty by me, or in the event that I, my minor child(ren) or ward(s), or any other person nevertheless asserts any claim against HK arising out of my or my minor child(ren)'s or ward(s)' participation in any program, event, class or other activity as set forth herein, I agree to indemnify, hold harmless and defend HK from and against any and all liability, claims, losses, costs, expenses or damages resulting therefrom, including, but not limited to, claims of loss, damage, illness or injury to person or property whether or not such loss, damage, illness or injury results from the negligence of HK or from some other cause.

I expressly acknowledge and agree to the terms and conditions set forth on this Participant Waiver Form.

Please attach the first page ONLY of one of the following documents: IEP, 504 Plan, Axis-I-IV diagnosis or physician letter. Please ensure that the document that you are sending, clearly shows the applicants disability.