Youth Programs Registration

Complete and submit the form below to register your children for the Malone Early Achievers Program, the Malone After School Program, and/or the Malone Summer Camp Out-Of-School Program. You will have the option to select which program(s) you wish to register for on the form. Choose the program(s) that best suits your needs.

Enter Child Information for all children who will attend (up to 4). And remember to download the Child Immunization Form, fill it out, and bring it with you to your scheduled Intake Interview.

Youth Programs Registration Form

Parent/Guardian Information
Child Information

Parent/Guardian Information

Parent First Name

Parent Last Name

Parent Phone

Is there a 2nd parent in the home?

Yes

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email

Parent 2 Phone

Address 1

Address Line 2

City

State

Zip Code

Country

Are you currently employed?

Yes

Employer Name

Are you a student?

Yes

School Name

Child Information

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age?

Child's Grade (in School)?

Child's School Name

Child's Gender?

Child's Race / Ethnicity?

Add a 2nd Child who will attend?

Yes

Child 2 Information

Child 2's First Name

Child 2's Last Name

Child 2's Date of Birth

Child 2's Age?

Child 2's Grade (in School)?

Child 2's School Name

Child 2's Gender?

Child 2's Race / Ethnicity?

Add a 3rd Child who will attend?

Yes

Child 3's First Name

Child 3's Last Name

Child 3's Date of Birth

Child 3's Age?

Child 3's Grade (in School)?

Child 3's School Name

Child 3's Gender?

Child 3's Race / Ethnicity?

Add a 4th Child who will attend?

Yes

Child 4's First Name

Child 4's Last Name

Child 4's Date of Birth

Child 4's Age?

Child 4's Grade (in School)?

Child 4's School Name

Child 4's Gender?

Child 4's Race / Ethnicity?

Emergency Contacts

Primary Emergency Contacts are person(s) to whom the Child or children may be released to by the caregiver.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Email

Emergency Contact Phone

Primary Emergency Contacts Relationship to Child/Children?

I will need The Malone to pick up my kid(s) from school?

Yes

Secondary Emergency Contacts

Secondary Emergency Contacts are person(s) who will take responsibility for the Child(ren) in an emergency when the parent(s) cannot be reached.

Secondary Emergency Contact First Name

Secondary Emergency Contact Last Name

Secondary Emergency Contact Email

Secondary Emergency Contact Phone

Secondary Emergency Contacts Relationship to Child/Children?

Child Immunization Record

Bring a signed copy of the Child Immunization Form with you to your scheduled Intake Interview. After completing and submitting the rest of this form we will email you confirmation of your Intake Interview.

Download the Child Immunization Form

Download & View the Parent Information Brochure

Weekly Attendance Schedule

After-School Program Schedule

After School Program runs August thru May.

Select the After School Program Days/Times you want:

After School Monday: 3:00PM - 5:00PM CST

After School Tuesday: 3:00PM - 5:00PM CST

After School Wednesday: 3:00PM - 5:00PM CST

After School Thursday: 3:00PM - 5:00PM CST

After School Friday: 3:00PM - 5:00PM CST

Summer Camp Program

Summer Camp runs 8 weeks starting in June.

Select the Summer Camp Program Days/Times you want:

Monday: Full-Day (8:00AM - 5:00PM CST)

Tuesday: Full-Day (8:00AM - 5:00PM CST)

Wednesday: Full-Day (8:00AM - 5:00PM CST)

Thursday: Full-Day (8:00AM - 5:00PM CST)

Friday: Full-Day (8:00AM - 5:00PM CST)

Early Achievers (Pre-School) Program Schedule

The Early Achievers schedule runs year round, Monday - Friday, 7:30AM - 5:00PM (CST)

Select the Malone Early Achievers Program Days/Times You Want:

Early Achievers Monday: 7:30AM - 5:00PM CST

Early Achievers Tuesday: 7:30AM - 5:00PM CST

Early Achievers Wednesday: 7:30AM - 5:00PM CST

Early Achievers Thursday: 7:30AM - 5:00PM CST

Early Achievers Friday: 7:30AM - 5:00PM CST

Pricing:

Early Achievers' Academy:

Full-Time: $232.50/week
Part-Time: $172.50/week
Daily: $46.50/day

Out of School Program:

Full-Time: $200.00/week
After-School: $180.00/week
Daily: $40.00/day

Details:

Full-Time: 5+ hours a day / 5 days a week
Less than 5 hours a day / 5 days a week
Pay the daily rate x the number of days each week your child attends (for 5+ hours a day).

Payment Types:

Private Pay - Payments made by an individual.
Subsidy (Title XX) - Qualify for DHHS coverage

Additional Payment Terms:

Payments are due Friday of each week for the next week of service. You may make advance payments.

Subsidy authorizations must be received by the Malone before services are provided.

DHHS subsidy co-payments are due the 1st business day of each month. You may make advance payments.

Please contact Karla Brown, Youth Programs Director with questions, or for more information call 531-500-5223.

Authorization for Release of Information

Part II Release of Information TO LPS by Another School, Entity or Person:

I hereby authorize the Disclosing Party and its employees and agents to disclose education and other records in the possession or control of the Disclosing Party to LPS.

You are authorized to disclose the following records and information:

All records about student and any other information requested by LPS

Scholastic Grades

Psychological Evaluations

Activity Records

Discipline Records

Health Records

Standardized Test Scores

Special Education Records

Unless otherwise stated, I request that this authorization be considered as valid until I revoke it in writing. *

Part III Release of Information by LPS to Another School, Entity, or Person

The purpose of this disclosure is to enable receipt of Malone Center services. *

Part IV FERPA Notice:

Provisions of the Family Education Rights and Privacy Act (FERPA) require parental or guardian permission in order to release non-directory information about students under 18 years of age. Those individuals 18 years of age or over may have information released upon the authorization of their own signature. Lincoln Public Schools will provide copies of records at the request of another school district where the student seeks or intends to enroll. Records from other sources (i.e., letters from non-school staff members, hospital reports or outside assessment agencies, etc.) which ware used in educational planning and have been placed in the student's record at the parent's request will be forwarded.

For Questions Contact:
Lincoln Public Schools, Department of Student Service
5905 O Street
Lincoln, NE 68510
Phone: (402) 436-1688

Parents Consent

In order to assure that all policies and procedures are followed, we ask each guardian to read and indicate Yes or No to the listed items.

Does your child use an inhaler?

Yes

Does your child use insulin?

Yes

I give my permission for staff to escort my children off the program premises for field site visits. I give staff permission to transport my child for the purpose of program activities whether by: City bus system, van , or by walking during any of the days at the program. Parents will be notified when we leave the site.

Yes

I give my permission for staff to apply sunscreen, chap stick, lotions as needed, sunscreen will be applied liberally, for outdoor play, field trips, and especially water activities. Program staff will supply the child with adequate sunscreen and/or assist the child with the application.(Product fact sheet is available for review at the program location for the sunscreen provided by canter.) (Bring your own Chap Stick.)

Yes

I give permission for staff to apply insect repellant when necessary. We often apply more replellant to clothing than skin. Program staff will apply the insect repellant. (Product Fact Sheet is available for review at the program location).

Yes

My Child may participate in routine assessment procedures (this may include photographs or audio or video-taping) which are considered part of the regular teaching program carried on in the laboratory. 1) It Is understood that I will be informed, in advance, of any research project in which my child might participate and will be asked to give my signed consent for their participation. 2) It Is further understood that the results of any teaching, testing, and research procedures, in which my child is Identified, are confidential and will not be released to any other agency without signed permission from me.

Yes

I give my permlssion for staff to share contact information (email, address, phone numbers) to other enrolled families in the program.

Yes

In the event of any emergency, I authorize staff and cooperating agencies/organizations to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary.

Yes

I have received a copy of the Department of Health and Human Services Parent Information Brochure for Licensed Child Care. (DHHS Nebraska pamphlet mailed in the enrollment packet)

Yes

I have read the illness criteria and the health contract and agree to follow it in determining when to keep my child home. I understand it is important that children be removed from the center if ill to limit the spreading of germs to other children and staff. I agree to pick up my child when he/she becomes ill at the center within 1 hour after I am contacted and agree to keep my child home until he or she has been symptom free for 24 hours and has met the program guidelines before retruning to care. I agree to follow medication procedures outlined on the health contract. Any medicaiton brought to school is to be given to a paid staff member and the parent will sign in medication witht he staff member as a witness.

Yes

My child has dietary restrictions due to allergies or family beliefs.

Yes

List what foods the child is allergic to:

My child must take medication in the classroom for a medical condition. I have a doctor's note.

Yes

List the medication(s) the child must take:

Competency Statement

I have determined the staff to be competent to give and apply medication to my child, I understand that the Director has the responsibility to assess the ability of staff to give or apply medication safely and may give or apply medication to my child.

Waiver, Release, and Discharge, Acceptance of Responsibility and Acknowledgment of Risks

This document affects your legal rights. You must read and understand it before signing it.

Community Center's Program(s)

For the benefit of the Clyde Malone Community Center, a Nebraska nonprofit corporation (the "Center"), and its directors, managers, agents or employees and any person facilitating any of the Center's programs (collectively the "Released Parties"), the Participant agree to the following:

Participation in the Center's programs involves risky of injury. Participant is responsible for participant's own safety. If the participant is a minor, the participants parent or guardian is responsible for the participant's safety.

The Participant fully understands and acknowledges that participation in the Center's programs involves risk of injury. The Participant does not have any physical illness or injury that would prevent the Participant from safely participating. The Participant understands that if he or she has any questions or concerns regarding his or her ability to safely participate in the Center's programs,the Participant should not and will not participate.

The Participant agrees to conduct himself or herself with care and under control at all times and to comply with all instructions given. The Participant hereby expressly agrees and covenants to accept and assume all risks and dangers and all responsibility for any losses and damages, whether caused in whole or in part by the negligence or other conduct of the Released Parties, by any other person, or by any latent or apparent defects or conditions in the property or equipment used by the Participant.

The Participant, on the Participant's own behalf and on behalf of the Participant's personal representative and heirs, hereby voluntarily releases, waives, discharges, and agrees to hold harmless, defend and indemnify the Released Parties from any and all claims, actions or losses for bodily injury, property damage, loss of services or otherwise which may arise out of the Participant's participation in the Center's programs. The Participant further agrees and covenants not to sue, assert or otherwise maintain a claim against any of the Released Parties for injury, death, illness or damage to the Participant or the Participant's property arising from or connected with Participant's participation in the Center's programs.

Waiver 1

I have read the above waiver and release and by signing it, I agree to its terms. It is my intention to exempt, relieve, indemnify, and hold harmless the Released Parties from liability.

Waiver and Release of All Claims

In consideration, the undersigned parent(s) or guardian(s) of the participant in the Malone Community Centers Program, I/we recognize and acknowledge that there are certain risk of physical injury and I/we agree to assume the full risk of any injuries, including death or loss which the undersigned or my minor child/ward may sustain as a result from participation in any and all activities connected with or associated with such program. I/we do hereby declare that I/we waive all claims of whatsoever kind or nature against the Malone Community Center, its officials, officers, agent, employees, and volunteers from any and all claims arising from injuries, including death, damage or loss which I/we or minor child or ward may incur or may accrue to me or my minor or ward on account of participation in the activities of this program. I/w further agree to indemnify and hold harmless and defend the Malone Community Center, its officials, officers, agent, employees, and volunteers from any and all claims resulting from injuries including death, damage, and losses sustained by the undersigned or my minor child or ward or arising out of the program.

Waiver 2

I/we have read and understand the above waiver and Release of All Claims and understand the effect of the relinquishment.

Consent Form for Photographs and Videos

Malone recognizes the need to ensure the welfare and safety of all families taking part in any activity associated with our organization. The Malone Community Center will not permit photographs, video, or other images of program participants to be taken without consent. We would like to ask for your consent to take photographs/videos during programming that may contain images of you or your child. It is likely that these images may be used as:

A record of the activity or the event
Grant purposes
Publicity material for further activities or events on pamphlets/websites/social media and other marketing materials
Illustrations of the activities or events in published articles
Future grant applications

The Malone Center will take all steps to ensure these images are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately you should inform Malone Center staff immediately.

Waiver 3

I/we have read, understand and consent to the above Photographs and Videos release.

Enrollment Questionnaire

Due to grant reporting and tracking purposes the information below needs to be answered truthfully and completely.

Race/Ethic Identity (Select all that apply):

Native American or Alsaska Native

Tibetan

Vietnamese

Asian

Cape Veridan

Jamaican

Black or African American

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

Puerto Rican

Columbian

Brazilian

White/Caucasian

Multi-Racial

Hispanic or Latino

Other

I’d rather not say

Family Information

Select your household family size:

Select your household family structure:

Child Information

Does your child have an IEP/504 plan with LPS?

Yes

Has your child ever been suspended from school?

Yes

How many times suspended?

Does your child currently attend therapy?

Yes

Behavior Intervention/Discipline Policy

At the Malone our vision is to create unity and prosperity throughout Lincoln while honoring our African American Heritage. We also strive to provide enriching, educational experiences for all children as much as possible.

We also strive to help every child be successful and to achieve their highest potential. We implement the Behavior Intervention Policy when needed to ensure this happens.

The basis for our Discipline Policy is an organized classroom and prepared staff members. At Malone we strive to develop a positive relationship between the teacher and the child. We also believe that if an interesting and challenging program is offered to the child, then discipline problems will be at a minimum. If inappropriate behavior does occur, we begin with a positive approach.

A Behavior Intervention Meeting may be called in three different manners:

The primary teach or member of the Leadership Team may call for a Behavior Intervention Meeting at any time prior to the third disciplinary action as they deem necessary.
Either parent may call for a Behavior Intervention Meeting at any time prior to the third disciplinary action as they deem necessary.
A Behavior Intervention Meeting is mandatory after the third Discipline Note.

Under the first two scenarios, our first goal will be to determine and identify the behavioral difficulties that the child is having. The child's primary teacher will document the circumstances surrounding the behavior and the current actions that are being taken to correct this. Parents will then be asked to provide information concerning any changes in the home and will give input if they have noticed this behavior and what actions they are currently taking to correct it. A plan of action will then be discussed and agreed upon by all members present. If problems continue, an additional intervention meeting will be scheduled.

This approach will vary slightly in the case that a mandatory Behavior Intervention Meeting has been called after the third discipline e note. Our first goal will be to determine if our program is appropriate for the needs of the child. Services will be terminated if it is determined that we cannot meet the child's needs in our program. We will follow the steps listed above if we determine our program is appropriate for the child's needs.

Behavior Intervention/Discipline Policy Consent

I consent to the Behavior Intervention/Discipline Policy.

Malone Parent, Child, and Van Expectations

Malone Center Expectations are designed for the safety of both staff members and attendees. These are put in place to reassure that participants and staff commute from point A to point B without experiencing any harm. Although outside factors can prevent the safely of passengers, we as a program want to make sure we are exercising the best safety protocols within our own center in the best way possible. PLEASE take the time to sit down to go over this document with you AND your child/children. Please feel free to ask any questions or concerns that may occur.

Parent Expectations:

COME INSIDE or UP TO STAFF MEMBERS and pick up/sign out your child. This will allow us to build a positive relationship and inform you all of any upcoming events, important dates, and other information.
Do your best to notify verbally or in writing of:
- Early pickup
- Someone besides the parent is picking them up. Anyone other than the parent must be listed on enrollment form and provide proper identification for release of child.
- Absent
Pick-up child by 5pm. A late charge of $1 per minute will be charged at pick up after 5:15pm. Your child will NOT be able to return until the late fee is PAID IN FULL. Transportation will NOT be provided home. If transportation difficulties occur PLEASE NOTIFY Malone Center IMMEDIATELY!
DOWNLOAD Himama. Turn on notifications and check emails 1 to 2 times daily.
Encourage your child to follow and obey Malone Center expectations.
Actively participate in required conferences, events, and other center activities (if possible).
Actively participate in any family therapy sessions.
FIND TIME to help kids with school work. They look up to you as parents! If they see you struggling, but you are trying to help them, they will embrace that and it may change the way they look al school work and other educational activities.
BE THE CHANGE! Do your best to change bad habits into good ones (sleep, eating, activities, things you interact with). If YOU CHANGE FIRST, your child will follow.

Child Expectations:

RESPECT ALL guests, staff, other children, and yourself by using manners, kind words, and appropriate actions.
KEEP hands and feet to yourself and use objects properly.
Stay in YOUR assigned area. DO NOT leave without permission from staff.

Transportation Consent

I hereby authorize the Malone Center (or "Center") to allow my child to be released from school and transported in "Center" vans to and/or from the Malone Center during program hours. I also give permission for my child to be transported in "Center" vans for sponsored outings and field trips.

Malone Center Van Policy & Procedures

While riding in any "Center" vehicle, all children, passengers, and staff shall follow all guidelines stated.

Sit in appropriate safety device (i.e. car seat, booster seat, seat belt).
Sit on their bottoms facing foiward with their seat belts tight.
Use appropriate language, no profanity, no inappropriate topics, use appropriate tone.
Use inside voices, no yelling or screaming
Food, gum, candy, and drinks are not allowed unless the "Center" has provided them and Center drivers have asked you to consume them in the van.
All trash is to be put in the trash bag in the vehicle.
No climbing over the seat backs .to get in or out of the van.
Hands, arms, feet, and legs are to be kept to oneself.
Hands, arms, fingers, feet, and toes are to be kept Inside the vehicle at all times.
The children will wait for the row in front of them to dismiss before exiting their own row.
If an issue arises, the driver will pull the vehicle over to deal with the situation safely. If needed, the driver or another staff member will call the appropriate authorities (i.e., The "Center", parents, Lincoln Police Department, etc.).

Failure to follow these guidelines may result inthe child's inablity to participate in "Center" sponsored outings an/or ride in their vans. Behavior that presents an immediate risk to the child or other children an staff in the van will result in a seven (7) day suspension from "Center" programming. Parents/guardians will be held financially responsible for any damage to "Center" vans caused by their child.

Van Policy & Procedures Consent

I understand what I have read and consent to the Malone Center Van Policy & Procedures listed above.

Payment

Pricing:

Early Achievers' Academy:

Full-Time: $232.50/week
Part-Time: $172.50/week
Daily: $46.50/day

Out of School Program:

Full-Time: $200.00/weekAfter-School: $180.00/week
Daily: $40.00/day

Details:

Full-Time: 5+ hours a day / 5 days a week
Less than 5 hours a day / 5 days a week
Pay the daily rate x the number of days each week your child attends (for 5+ hours a day).

Payment Types:

Private Pay - Payments made by an individual.
Subsidy (Title XX) - Qualify for DHHS coverage

Additional Payment Terms:

Payments are due Friday of each week for the next week of service.
You may make advance payments.
Subsidy authorizations must be received by the Malone before services are provided.
DHHS subsidy co-payments are due the 1st business day of each month. You may make advance payments.

Please contact Tyrina Webster, Director of Operations with questions, or for more information.

Signatures

Two Parent/Guardian signatures are required if child/children lives with two Parents/Guardians.

You agree that by entering your name into the “Signature” field below on this Agreement your are legally “signing” this agreement, and that this digital signature is the same as your providing a handwritten signature for the purposes of providing legal validity, enforceability, and admissibility. By signing you are also indicating that you are a legal guardian of any minor children who are covered under terms of this Agreement.

Parent 1 Signature:

Parent/Guardian 1 Signature

Parent/Guardian 1 Signing Date:

Parent 2 Signature:

Parent/Guardian 2 Signature

Parent/Guardian 2 Signing Date: