2024 Westminster Summer Program Registration
Please complete this application in its entirety. Contact the Youth Services Director, Brouke Wright, at brouke.wright@westmin.org with any questions. 
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Student's First Name *
Student's Last Name *
Student Date of Birth *
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Student Gender *
Student Race *
Primary Language *
Parent First Name  *
Parent Last Name *
Cell Phone Number *
Email *
State *
Zip Code *
How many people in your household *
School *
Current Grade Level *
Does your child have special needs that we need to be aware of?  *
Does your student have an IEP/504?
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If Yes, what special needs do we need to be aware of?
Does your child have any food/drug allergies?
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List of food/drug allergies
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Things that Help my child
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Emergency Contact 1: First Name
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Emergency Contact 1: Last Name
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Relationship to student *
Emergency Contact Phone Number
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Emergency Contact 2: First Name
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Emergency Contact 2: Last Name
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Relationship to student
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Emergency Contact Phone Number
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Emergency Contact 3: First Name
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Emergency Contact 3: Last Name
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Relationship to student
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Emergency Contact Phone Number
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Emergency Contact 4: First Name
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Emergency Contact 4: Last Name
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Relationship to student
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Emergency Contact Phone Number
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Do you receive any of the following? *
Required
Do You Need Assistance with the Following
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Required
Would you like to apply for a full/partial scholarship?
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*WNS will make every effort to use positive methods of guidance and discipline as we teach your child how to work through problems. Positive guidance is an ongoing process as children develop self-control and learn to behave in a socially acceptable manner. Any person, while on WNS premises, shall not engage in or direct any of the following actions toward children: Inflict corporal punishment in any manner upon a child’s body Hit, spank, beat, shake, pinch, or any other measure that produces physical discomfort Cruel, harsh, unusual, humiliating, or frightening methods of discipline, including threatening the use of physical punishment Placement in a locked or dark room Public or private humiliation, yelling, or abusive or profane language Caregiver shall not: Associate disciplinary action or rewards with rest Associate disciplinary action with food or use of food as a reward Associate disciplinary action or humiliate a child in regard to toileting Use time out for any child less than 3 years of age Use time out for any purpose other than the enable the child to regain control Physically restrain children except when it is necessary to ensure their own safety or that of other and only for as long as is necessary for control of the situation Use punishment to correct unacceptable behavior If your child’s behavior is very disruptive or harmful to himself or other children, the staff will discuss the issue with you privately. If the situation can be resolved, the child may remain enrolled. If we are unable to resolve the issue, you may be asked to make other arrangements for service.
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The following steps will be taken to ensure your child(ren)’s safety while at Westminster Neighborhood Services. Children will be actively supervised with the required number of qualified adults. Adults will pass a comprehensive criminal background check, drug screen, and TB test and have completed all required trainings. WNS will not care for children in areas that are being remodeled, repaired, or painted. The Director is responsible for maintaining all interior and exterior surfaces, walls, floors, ceilings, equipment, toys, and furnishings in a safe condition, free of sharp points or jagged edges, splinters, protruding nails or wires, loose parts, rusty parts, or materials containing poisonous substances. WNS will take the following steps to maintain the center: Daily cleaning Always keep the center in a sanitary condition Sanitize toys, furniture, and other equipment used by children weekly and when they become soiled or contaminated. Wash all soiled items prior to sanitation.
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*I give permission for my child to wear insect repellent. I understand that my child will use insect repellent provided by Westminster Neighborhood Services, Inc. unless I provide insect repellent with my child’s namely clearly printed on the bottle. The staff have my permission to apply/reapply insect repellent as needed throughout the day.
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I give permission for my child to wear sunscreen. I understand that my child will use sunscreen provided by Westminster Neighborhood Services, Inc. unless I provide sunscreen with my child’s namely clearly printed on the bottle. The staff have my permission to apply/reapply sunscreen as needed throughout the day.
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My child has my permission to receive the topical medications (antibiotic ointment and afterbite) from the staff of Westminster Neighborhood Services, Inc. *
*I hereby grant Westminster Neighborhood Services, Inc. (“WNS”) and their agents the absolute right and permission to use photographic portraits, pictures, digital images or videotapes of My Child, or in which My Child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any WNS publication or on the WNS websites, without payment or any other consideration. I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein My Child’s likeness appears, or the use to which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless WNS and their agents from all claims, demands, and causes of action that I or My Child have or may have by reason of this authorization or use of My Child’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials. I represent that I am at least eighteen (18) years of age and am fully competent to sign this Release. THIS IS A RELEASE OF LEGAL RIGHTS. READ IT CAREFULLY AND BE CERTAIN YOU UNDERSTAND IT BEFORE SIGNING.
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I hereby authorize my child's teacher/school to release student record information, including names and addresses, grades, standardized testing scores, reading level assessments, and behavioral and attendance data to Westminster Neighborhood Services, Inc. I understand that only Westminster Neighborhood Services, Inc. and their authorized agents will have access to the information released about my child. Student information, including names and addresses will not be given to others for any purpose. This information will be utilized only by Westminster Neighborhood Services, Inc. to implements and support the Youth Services Program, to evaluate the Youth Services Program, and to inform donors and grant organizations of student progress and data. When reporting, data will be reported as a group and individual student names will be left off of the report.
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Westminster maintains a relationship with a Licensed Clinical Social Worker (LCSW). This LCSW meets regularly with our students individually or in small groups to provide them the opportunity to discuss anything they wish. Privacy and Confidentiality means our LCSW has a responsibility to you to safeguard information obtained during a meeting. All identifying information about your students and/or family is kept confidential. Even within our organization, information about your student and/or family is only shared with pertinent individuals. It is important that you understand that the laws of the State of Indiana mandate exceptions to confidentiality in specific cases. In certain situations, mental health professionals are required by law to reveal information obtained during meetings to other persons or agencies without your permission. For example, in instances of abuse or neglect. By signature below, I confirm and agree that the LCSW will meet with my student as needed and attempt to assist my student in developing healthy coping skills and self-regulation, but that they do not make any representations or warranties with respect to the results of their services and/or referrals, or their ability to help me with my emotional management. I further acknowledge that I have been informed of my rights and give my permission for my student to meet with the LCSW contracted by Westminster.
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Payment must be made in full weekly or monthly. If a child is picked up late there will be a $1.00 per minute late charge after the first incident. This fee must be paid in full by the next business day. If you are unable to make a payment on time, please discuss with WNS Administration. Failure to communicate financial hardship may result in Termination of Care.

By typing your name below, you are indicating that you have reviewed, understood, and agreed to follow the Parent Handbook provided on the WNS website:
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I understand that if I choose to pick up my student prior to 5PM that my student may be out of the building. I understand it is my responsibility to communicate with Westminster staff if I need to pick up early. I understand staff may be unable to change plans and I may need to pick up my student from an off-campus location
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I understand the cost of the Summer Program and that I may be eligible for a reduced rate or scholarship.
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*I understand that my student's application is not considered complete until all required information, documents, and fees have been received.
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*I understand K-8 Summer Program opens at 7:30 a.m. and closes at 5:30 p.m. Students must arrive by 9:00 a.m. There is a $1.00 per minute late pick up fee.
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I have completed the registration form to the best of my ability. I understand further supporting documentation (immunization records, income verification, custody agreement, etc.) is required before my student will be considered enrolled. I understand my student is not considered enrolled until all required forms have been received and reviewed, all required signatures are complete. I understand my student is not considered enrolled until I have completed a new parent orientation with a WNS staff member. (New parents only) I understand Summer Program ends at 5:30 PM. There is a $1 per minute late fee. I can check my Parent Handbook or ask a WNS staff member should I have any questions or concerns about program. I will not send a sick student to the program. I will inform WNS if my child will not be attending program for the day. My child will be signed in/out each day by an authorized person. I will inform WNS of any changes in: address, telephone number, income, etc. that may affect my child's enrollment. I understand The Westminster reserves the right to dismiss any child(ren) exhibiting the following behaviors: Disruptive and/or damaging behavior in accordance with the Westminster Behavior Policies. If, after a period and conferences between the parent and Youth Services Coordinator, a child is unable to adjust to the expectations and rules of the Westminster Youth Services Program and is causing disruptive and/or damaging behavior to persons and/or property, the child(ren) may be asked to leave. If a child and/or parent is verbally abusive and/or physically abusive with another child or with a staff member, that child/parent may be withdrawn from the program. WNS is required by law to report any suspected child abuse or neglect to the Indiana Department of Child Services.
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