Ivy League Kids: E-learning Center

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Email *

Today's Date: *

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Child's Name *

Child's Date of Birth *

YYYY

Primary Parent/Guardian Contact Name *

Best Contact Number: *

Address: *

Current School Grade: *

School Name: *

Emergency Contact Name #1/Relation to Child: *

Emergency Contact #1 Phone Number:

Emergency Contact #2/Relation to Child: *

Emergency Contact #2 Phone Number: *

Does your child have any allergies? *

What subject(s) does your child need the most help with? *

What are your child's hobbies/favorite things to do?

Is there anything you'd like to share with Ivy League Staff about your child? (Ex. My child is shy and needs more confidence to make friends.) *

The state of Illinois moved into Phase 4 of Governor Pritzker's Restore Illinois plan. In Phase 4, all small gatherings are allowed with this limit subject to change based on latest data and guidance. We recognize these circumstances change daily, especially in light of present events, and we plan to keep you informed regarding any changes. Attendance at the Ivy League Kids E-learning Center is at the discretion of each parent or guardian. If any student is at heightened risk due to COVID-19, they should not attend this program, and the parent or guardian is responsible for informing Ivy League Kids staff. Heightened risk factors include advanced age, respiratory illness, diabetes and immune system suppression, and many others. The CDC provides further guidance at the following link: https://www.cdc.gov/coronavirus/2019-ncov/index.html Please initial the space below in acknowledgment of the information above.

Communicating about COVID-19 and RIsk Factor-Each parent should assess their child's health directly every morning prior to Ivy League Kids E-learning Center attendance. Is your child(ren) feeling achy? Do they have a fever or chills? Fatigued? Cough or chest tightness? Unusual digestive issues? Unknown rash? Before bringing your child(ren) to the program, all parents should do this evaluation and discuss health with their child(ren) to determine if they are feeling well and able to attend. In the case that your child(ren) or someone in their household have been exposed to someone with COVID-19, to a large gathering of people, or anyone showing symptoms, your child must not attend the Ivy League Kids E-learning Center. If there are any known cases or risks at the Center, staff will close and inform parents immediately. As Ivy League Kid's staff care for your children, you may expect open and honest communication at any time. The relationship between staff and participant families are very important to us. We need to be open and honest with one another so we can protect one another and work together to make the best informed decision everyday. Please initial the space below in acknowledgment of the information above. *

Daily Protocols-Each child must wear a mask at all time during the day. Parents/guardians are required to send their child(ren) with a face mask daily. In the case that they lose their mask, the elastic breaks, or cannot use the one sent with them for any reason, the site will always have them in stock to replace it and maintain this procedure. For more information about appropriate masks, mask cleaning and hygiene, you can refer to this link: https://www.chicagotribune.com/consumer-reviews/sns-bestreviews-health-clean-and-sanitize-face-masks-20200429-srmekc Washing hands and sanitizing frequently, and maintaining six (6) feet of distance when possible. I have read the agency's COVID-19 Contact Guidelines for the Ivy League Kids E-learning Center and I agree to adhere to all items listed to the best of my ability. I understand I am not obligated to send my child(ren) and that I am expected to keep my child(ren) at home should they display symptoms as listed on this form. I will make daily decisions based on what is bet for the safety, health, and wellness of each person in attendance at the Ivy League Kids E-learning Center, as well as my family. I will discuss these considerations in depth with each child(ren)and ensure we are all in agreement before proceeding. If I have questions or concerns about how best to do this, or about any of the guidelines listed here or any other concerns related to Ivy League Kids E-learning Center, I will contact the Program Director of Adults Active in Youth Development, Inc. I will not hold Adults Active in Youth Development, Inc. or it's directors, officers, employees, or other staff responsible if I or one of my family members or other personal contacts interacting with the Adults Active in Youth Development organization for any damages that may result from contracting COVID-19 or any illness. I will not hold Adults Active in Youth Development, Inc. responsible for any damages that may results from contracting an illness, including all liability, claims or demands arising from any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. This release is binding on heirs, executors, administrators, assigns, agents, attorneys and representatives.

Please sign in the space provided: If this form is being completed via electronic device, your electronic signature as well as a physical signature is legally binding to your acknowledgment and consent to all of the listed terms, conditions, and information provided.

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