<p>Dear Parent or Guardian,</p><p>Welcome to WK Unplugged!</p><p>We would like to invite your child to join us for an exciting extension of the Whiz Kids program! WK Unplugged is an educational, spiritual and personal enrichment program that is designed to meet the growing needs of your students as they continue to mature in their academic, personal and spiritual life.</p><p>WK Unplugged is a free enrichment program that will take place at (location), on (day/time). This weekly program will consist of academic life application, small group discussion, and will include a curriculum that covers life and job skills, academic comprehension, and spiritual growth.</p><p>The volunteer coaches come from the local community</p><p>. WK Unplugged requires all volunteers to undergo a comprehensive background security check using a locally and nationally accredited screening program called Selection.com to ensure the safety and security of the children participating in the program. Additionally, all coaching will take place in a group environment and supervised by an adult volunteer at all times.</p><p>If you are interested in your child taking part in this free enrichment program, </p><p> please completely fill out the attached 3-page application and return it as soon as </p><p> possible to (contact name/phone number) If you have any questions about the program or the application, you can contact me or the WK Unplugged /City Gospel Mission office (513-345- 1041). Thank you! We look forward to working with your student! Student’s name</p><p>Gender Male [ ] Race/Ethnicity Asian [ ] Black/AA [ ] Hispanic/Latino [ ] Female [ ] White [ ] American Indian [ ] Pacific Islander [ ] Appalachian [ ] Date of Birth/ Birth Date: Grade: Grade School/ Teacher School Name: Teacher Name: Home Church Name (if applicable): Name/Home Church Name</p><p>Parent/Guardian 1 Emergency Contact Yes [ ] No [ ]</p><p>Street Address </p><p>Phone Number 1 City State Zip Code Phone Number 2 Home [ ] Cell [ ] Work [ ] Home [ ] Cell [ ] Work [ ] Email Address</p><p>Email Address</p><p>Parent/Guardian 2 Emergency Contact Yes [ ] No [ ]</p><p>Address </p><p>Phone Number 1 Home [ ] Cell [ ] Work [ ] Phone Number 2 Home [ ] Cell [ ] Work [ ]</p><p>Additional Contact Emergency Contact Yes [ ] No [ ] Phone Number 1 Home [ ] Cell [ ] Work [ ] Phone Number 2 Home [ ] Cell [ ] Work [ ] Relationship to Student: </p><p>Site Leader, please fill out: Site Name </p><p>Student Start Date Name of Coach PARTICIPATION CONSENT, WAIVER, AND RELEASE</p><p>I give my son/daughter (Parent/Legal guardian) (Child’s name) permission to participate in the WK Unplugged program offered during the current school year at . By signing this document, I am documenting that I understand and agree to each of the following statements and that I agree to hold City Gospel Mission and its partnering church, agents, employees’ representatives, successors, and assigns (collectively “CGM”) harmless of and from any and all liability of whatever nature which may arise out of or result from my child’s participation in the Program as consented to in this document:</p><p> Faith-based activities : the Program is an initiative of City Gospel Mission, which is a Christian faith- based organization, and my child permission will be involved in faith-based activities as they present themselves during the Program.  Transportation : The authorized members of CGM may secure travel for my child to and from the Program and any and all activities related to the Program.  Publicity : CGM may use my child’s name and/or photograph(s)/video for the purposes of duplication, publicity and/or publication.  Communication with school : Members of the faculty at my child’s school may discuss my child’s grades, score and progress with his/her Program tutor. This will always be done in a confidential manner.  Evaluation: We ensure that our programs are working at maximum capacity and we are leveraging our budget to the best of our abilities. Quarterly we use a form called “ENDS” in order to provide checkpoints with the relationships built with participants in this program you are giving consent to that form be completed.</p><p>Acknowledgement of Understanding : I have read this Participation Consent, Waiver, and Release (this “Consent”). I understand the terms used in this Consent and have willingly placed my signature below as evidence of my acceptance of all the conditions stated in the Consent. I sign this Consent with the understanding that I, for my child and for me, am giving up any right to legal recourse against CGM for negligent conduct (but not for reckless or intentional conduct) in return for allowing my child or me to participate in Program activities. I understand that this Consent applies each and every time, and remains in effect for as long as, my child or I participate in any Program activities. By my signature below, I accept the terms of this Consent. Because I am signing this Consent on behalf of a minor, I certify that I am my child’s custodial parent or legal guardian with full authority to act on my child’s behalf with respect to everything addressed in this Consent.</p><p>Signature of Parent/Legal guardian Date EMERGENCY MEDICAL TREATMENT AUTHORIZATION</p><p>Purpose: To enable a custodial parent or guardian to authorize emergency medical treatment to his or her student if the student becomes seriously ill or injured while participating in the WK Unplugged’s Program and the custodial parent or guardian cannot be contacted .</p><p>FACTS ABOUT MY STUDENTS MEDICAL HISTORY 1. Does your student have any physical disabilities? Yes [ ] No [ ] If yes, please describe below.</p><p>2. Is your student currently taking any medications? Yes [ ] No [ ] If yes, please list below.</p><p>3. Does your student have any dietary allergies or restrictions? Yes [ ] No [ ] If yes, please list below.</p>