Mt. Carmel Workshops Registration

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Select a Workshop to register for: (Please choose no more than three Workshops)*

Workshop Information:
Location: Mt. Carmel Baptist Church
9610 E. 42nd St. – Indianapolis, IN 46235






STUDENT/PARTICIPANT INFORMATION

Please fill out the information below completely and entirely to ensure accurate programmatic records. Please be prepared to pay at the end of the registration for any program that has a fee listed on the program page.

Participant Name*






Participant Date of Birth*






Participant Ethnicity*















Please provide your students email if applicable.

Supportive Adult Email*




Participant Address*











Please provide the best phone number to reach the participant with important program information.

Is the student affiliated with any of these organizations?


















STUDENT/PARTICIPANT SCHOOL INFORMATION

If you are participating in a summer program, please choose the grade that your student will be entering in the fall.Please provide the complete school name (no acronyms) i.e. Warren Central High School not WCHSPlease provide the complete school district (no acronyms) i.e. Metropolitan School District of Perry Township not MSDPT

Is the student a 21st Century Scholar?*






Did the student FAIL last year?*




Does the Student have an individual Education Plan (IEP) or 504 Plan?






HOUSEHOLD INFORMATION

Supportive Adult Name*

The supportive adult is the individual completing this form, and who will be primarily responsible for receiving pertinent information.







Relationship to student?*


















Address*













Type of Household*






Student lives with (choose one):*















CONFIDENTIAL INFORMATION

The following information is for CLD to obtain funding as a non-profit organization. Names are never used or sold and the information is completely confidential. Your cooperation in providing this information is appreciated.

Total number of individuals living in household:*




















Does your child receive free/reduced lunch?*




Do you receive assistance from any of the programs below?*














Annual household income:*
















PROGRAM INFORMATION

Please indicate below which CLD Program or Initiative you are applying for. If you are applying for more than one CLD Program or Initiative, you must use separate application forms.

Is this the student’s first time participating in a CLD program?*




How did you hear about the program you are registering for?*











































T-Shirt Size (Adult Sizes)*


















CAREER INTEREST

Hold [ctrl] to select multiple interests.Ex. Dentist, Nurse, Artist, Musician, Athlete, Mechanic, etc.

SUPPORTIVE ADULT CONSENT

Please read carefully prior to agreeing:*

Data clause: ISTEP, FERPA,

Supportive Adult, Parent or Guardian Stipulation and Waiver Agreement for Program and Service Participation

APPLICATION: Families must complete an application prior to attending any Center for Leadership Development (CLD) program. The deadline for completing an application is noon the day of the orientation. It is the parent’s responsibility to be informed and current with when and where orientations take place.

PAYMENTS: Payment is expected before the program begins. Failure to meet payment deadlines can result in non-participation in the program. Fees will not be refunded.

PARENT OR GUARDIAN PERMISSION: I have the legal authority to submit an application for the child(ren) named and that to the best of my knowledge the information provided is complete and accurate. I further understand that this application and the named child(ren)’s participation is contingent upon space being available in the program. I also understand I must complete payments by the deadlines as outlined. Furthermore, all necessary health, security and waiver forms must be signed and on file with CLD prior to my child(ren) attending the program. Failure to comply with this could result in the loss of participation in the program. I give permission to CLD to use photos or videos of the person listed on this application.

Any data collected by CLD from various vehicles is private and confidential. Data may include, but is not limited to: ISTEP scores, CTBS, and standardized testing covered by FERPA, as well as grades, school attendance records, behavioral records and log sheets. It is also understood that data collected will protect my child’s identity, although CLD, its assigns, or successors may use the data to determine current trends. The data collected is the sole property of CLD.

PARENT OR GUARDIAN AUTHORIZATION: My child(ren) has medical approval to participate in the activities of CLD and in my judgment my child(ren) is in good health and physical condition and able to safely participate in the activities of CLD. My child(ren) has my permission to engage in all activities offered by CLD except as noted by me in writing. I certify that my child(ren) is amenable to discipline and free from habits or attitudes, which would make him/her an undesirable participant. I have studied the parent resources provided and understand the contents thereof. I further understand that neither CLD nor any of its paid staff or volunteer workers can be held responsible in the event of an accident. In consideration of my child(ren)’s participation in the activities of CLD, I promise and agree on behalf of myself, my spouse or partner or other family member not to sue and agree to waive, release, discharge, and hold harmless and indemnify CLD, its agents, employees, members and volunteer from all claims, demands, rights and causes of action of any kind, whether arising from my own acts or omissions, those of my child(ren), or those of CLD or other person. I hereby waive all claims for injury or damage suffered by my child(ren), myself, my spouse, my partner, or other family member in connection with or arising out of the participation of my child(ren) in CLD activities or use of CLD equipment or facilities. I understand CLD does not allow CLD employees to provide programs or services to participants outside of the approved CLD activities and sites. I understand that all CLD staff have been informed of this policy.

EMERGENCY AUTHORIZATION: In the event I am not able to communicate or cannot be reached in an emergency, I hereby give permission to the CLD staff to administer treatment as outlined on the medical form given one is required to participate in the program or service. If the emergency constitutes professional care or if no medical form is required to participate, I hereby give permission to the medical personnel selected by CLD staff to administer treatment as is medically necessary. I will be responsible for any costs of such treatment, even if not covered by insurance.

TRANSPORTATION AGREEMENT: I hereby give permission for my child(ren) to participate in CLD activities and to travel by bus with CLD staff. I understand that only licensed and qualified personnel will operate any vehicle to and from the site, and that there will be at least one staff member present at all times. I agree to release CLD, its officers and directors, and the CLD staff from any and all claims of damages, demands or liabilities which may arise as a result of my child’s participation on these bus trips.

ADULT CODE OF CONDUCT: CLD requires adults of participants to behave in a manner consistent with CLD values of Character, Education, Leadership, Service and Career. Achieving this ideal environment is not only the responsibility of the staff, but the responsibility of each and every adult who enters the program. Adults are required to behave in a manner that fosters this ideal environment. Adults who violate the code of conduct may be asked not to return to the program. Participants can be removed from the program based on inappropriate behavior of parent or guardian.
1. Swearing/cursing: No adult is permitted to curse, use other inappropriate language or inappropriate gestures in a CLD program or service, whether in the presence of children or not. This includes phone conversations and email exchanges with staff. Such language is considered offensive and will not be tolerated.
2. Threats: Threats of any kind towards staff, children or other adults will not be tolerated.
3. Confrontational Interactions: While it is understood that parents will not always agree with the staff or the parents the other children, it is expected that all disagreements be handled in a calm and respectful manner. Confrontational interactions are not an appropriate means by which to communicate a point and are strictly prohibited.
4. Addressing Program Participants: Adults are prohibited from addressing, for the purpose of correction or discipline, a child that is not their own. If an adult should witness a child behaving in an inappropriate manner, or is concerned about behavior reported to them by their own child, it is most appropriate for the adult to direct their concern to the staff. Parents are not permitted to spank or slap their own children while at program site.
5. Confidentiality: It is inappropriate for one adult to seek out another adult to discuss their child’s inappropriate behavior. All behavior concerns should be brought to the staff’s attention. The staff will address the issue with the other adult. Although you may be curious about the outcome of such a discussion, staff is strictly prohibited from discussing anything about another child with you.
6. Violations of Safety Policy: Adults are required to follow all safety policies at all times. These procedures are designed not as mere inconveniences, but to protect the welfare and best interest of the children and staff.

Electronic Supportive Adult Signature*





I understand that by entering my name in the boxes above, I am electronically signing this application form and agreeing to all terms and conditions provided. I have completed this form accurately to the best of my ability and understanding. My electronic signature has the same legal status as a handwritten signature.

Date Application Signed*






You may not move on unless the participant is a graduate of the Self-Discovery Program. Please select “Yes” to move on.