EmailMe Form - PLEASE DO NOT COMPLETE APPLICATION

EmailMeForm

STUDENT INFORMATION
Please ensure all information entered is accurate and current.
Student Name *
First Middle Last
A separate application must be completed for each student.
School Site *
Date of Birth *
MM / DD / YYYY
Gender *
Male
Female
MDCPS Student District ID Number *
Your student's Identification Number can be found on his/her report card. Please also ask your student this is their school lunch number.

(If you do not know your child's ID#, please type 999-9999)
Current 2024-2025 school year grade level *
Pre-K
K
1
2
3
4
5
Does your student receive free or reduced lunch? *
Yes
No
Transportation Mode: *
Walk
Bus
Pick-upp
Other
Student Race / National Origin *
Child Ethnicity *
Is the Student Proficient in English? *
Yes
No
Is this student Hispanic or Latino? *
Yes, Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)
No, not Hispanic or Latino
Unknown
Primary Language: spoken in your home *
English
Spanish
Haitian Creole/ French
Other
Check all that applies
Does child have health insurance? (ex., private insurance, KidCare, Medicaid) 0 Yes 0 No
(If not, we may be able to help you find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.) *
Yes
No
Head of Household *
Single Female
Single Male
Not a single head of house hold
Check all that applies
Student Home Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Education Program:
Select Education Programs *
Homeless
ELL/LEP
Special Education /ESE
Gifted & Talented
Bilingual
N/A
select all that applies to your student.
Does the student have a documented disability? *
Yes
No
If YES, you MUST provide supporting documentation and complete the next three questions.
If No, Please proceed to Parent/Guardian Information.
If yes, do you have
an Individualized Education Plan (IEP) from the school system
a Section 504 Plan
a medical diagnosis from a doctor
Other
Check all that applies
Upload Supporting Documentation
If you answered yes to the above, how would you best classify the type(s)?
Autism Spectrum Disorders
Chronic Medical Condition
Emotional and/or Behavioral Disorder
Hearing Impairment (or deaf)
Intellectual Disability (or mental retardation)
Learning Disability
Physical Disability
Speech/Language Impairment
Visual Impairment (or blind)
English Language Learner
Other
Check all that applies
PARENT/LEGAL GUARDIAN INFORMATION
Parent/Guardian Registered by Full Name *
First Last
Does the child live with a legal guardian other than mother or father? *
Yes
No
Parent Guardian Registered by Relationship to Student *
Mother
Father
Aunt/Uncle
Grandparent
Legal Guardian
other
If Parent/Guardian address is the same as student address please leave blank.

Street Address City State / Province / Region Postal / Zip Code Country / Region
Registered by Phone# *
### - ### - ####
Is the phone number above a cell/mobile phone?
Yes
No
Cell Phone Carrier *
Sprint
T-Mobile
Metro PCS
AT&T
Verizon
Boost Mobile
Cricket
Other
This is how you will receive updates and notifications via text messaging.
If your carrier is not listed, please click other and your site supervisor will add your carrier's name at a later date.
Parent/Guardian Email Address *
EMERGENCY CONTACT INFORMATION
YOU MUST COMPLETE A MINIMUM OF TWO EMERGENCY CONTACT. PLEASE ENSURE INFORMATION PROVIDED IS CURRENT and ACCURATE.
1. Emergency contact persons' FULL NAME FULL NAME *
First Last
Phone *
### - ### - ####
Email Address
1st Relationship to Student *
Mother
Father
Aunt
Uncle
Sibling
Grandparent
Family Friend
other
1st emergency contact address

Street Address City State / Province / Region Postal / Zip Code Country / Region
Is above person to be contacted in an emergency? *
Yes
No
Emergency contact will be notified for any reason the primary contact does not respond.
Is above person authorized to pick-up child? *
Yes
No
2nd Emergency contact persons' FULL NAME *
First Last
Phone *
### - ### - ####
Email Address
2nd Relationship to Student *
Mother
Father
Aunt
Uncle
Sibling
Grandparent
Family Friend
other
2nd emergency contact address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Is above person authorized to pick-up child? *
Yes
No
Is above person to be contacted in an emergency? *
Yes
No
Emergency contact will be notified for any reason the primary contact does not respond.
3rd Emergency contact persons' FULL NAME
First Last
Phone
### - ### - ####
Email Address
3rd Relationship to Student
Mother
Father
Aunt
Uncle
Sibling
Grandparent
Family Friend
other
Is above person authorized to pick-up child?
Yes
No
Is above person to be contacted in an emergency?
Yes
No
Emergency contact will be notified for any reason the primary contact does not respond.
STUDENT HEALTH INFORMATION
All health conditions including allergies MUST be disclosed to ensure student safety.
Are there any medical conditions or behavioral problems? *
Yes
No
If yes please explain
Does your child have any allergies (food, hay fever, Peanuts, etc.)? *
Yes
No
If yes please list allergies
Are there any activities the child may not participate in? *
Yes
No
If yes please list activities
HELP US GET TO KNOW YOUR CHILD
We want to get to know your child better so we can provide the best possible experience in our programs.
What are the main ways we in which your child communicates? (Mark all that apply) *
Speaks and is easily understood
Speaks but is difficult to understand
Uses communication devices like pictures or a board
Uses gestures or expressions like pointing,pulling,smiling,frowning or blinking
Uses sign language
Uses sounds that are not words like laughing, crying or grunting
What,if any, help does your child receive at this time? (Mark all that apply) *
Behavioral therapy or services
Counseling for emotional concerns
Daily medication (not including vitamins)
Occupational theraphy (OT)
Physical theraphy (PT)
Special education services in school
Speech/language therapy
None of the above
What conditions does your child have that are expected to last for a year or more? (Mark all that apply) *
Autism spectrum disorder
Developmental delay(only if under age 5)
Intellectual /Developmental disability (over age 5)
Hearing impairment or deaf
Learning disability(school age)
Medical condition or illness
Physical disability or impairment
Problems with aggression or temper
Problems with attention and hyperactivity (ADHD)
Problems with depression or anxiety
Speech or language condition
Visual impairment or blind
None of the above
If you marked "None of the Above" on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below.
Do any of the conditions marked above make it harder for your child to do things that other children of the same age can do?
Yes
No
To support your child's successful participation in this program, in what areas might s/he need extra assistance?
No Specific help needed
Holding a crayon/pencil, writing, using scissors or other fine motor tasks
Managing feelings and behavior
Academic, Learning or reading activities
Adapting activities to take into account a visual or hearing impairment
Using assistive device(s) like a wheelchair, crutches, brace or walker
Personal services like help with feeding , toileting or changing clothes
Other
Please tell us anything else you think it is important for us to know about your child.
Explain
PARENT CONSENTS AND DISCLOSURES
Consent to Medical and/or Surgical Treatment & Assumption of Risk and Release. In the event of injury to or illness of their son/daughter/ward, the undersigned hereby authorizes Big Ideas Educational Services, Inc. or representative thereof, to admit the registrant named to a facility for emergency medical treatment as may be deemed necessary to his or her health welfare. The undersigned hereby consents to whatever medical treatment is deemed necessary. The undersigned on his or her behalf of the registrant, their heirs, assigns and personal representatives, hereby releases Big Ideas, its commissioners, staff and employees from any and all claims arising out of the admission to, or treatment administered by, such facility. The undersigned hereby acknowledges and agrees that participation in the academic program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Big Ideas, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the academic program. Consent to Medical and/or Surgical Treatment & Assumption of Risk and Release. *
I agree
I disagree
I hereby authorize Big Ideas, and the members of its staff to take such photographs, television recordings and/or live television transmission of the registrant in whole, or in part, as they or members of the staff may wish, and to use and publish the same in such places and publications as Big Ideas, or its staff in its sole discretion consider to be of benefit to said parties. I hereby waive any right that I may have to inspect and/or approve the finished product that may be used here under or the specific use to which it may be applied. *
I agree
I disagree
I hereby authorize Big Ideas, to transport registrant on approved fieldtrips and outings. I understand that Big Ideas will use insured transportation companies to transport my child. The undersigned hereby acknowledges and agrees that participation in the summer camp program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Big Ideas, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the program. *
I agree
I disagree
WALKER FORM
I hereby authorize my child to walk to and from the program site. I understand that my child must enter the building and immediately go to the program area upon arrival. At dismissal, my child must exit and leave the grounds immediately, and not loiter in the building or in the bus loading area. The program reserves the right to revoke permission to walk at any time for actions deemed inappropriate. *
I agree
I disagree
If you agree, an additional release form will be provided. This form MUST be completed and notarized before services start.
I understand that to ensure all COVID-19 related safety procedures and onsite safety related dismissal procedures remain in place (i.e. ID checks and walker forms) dismissal will be decreased to our Procare curbside only. Authorized parents/guardians will remain in their vehicle, a Big Ideas staff member will identify authorized parent/guardian from a safe distance, and students will be called via walkie/talkie to go home. Students will not be released to unauthorized individual (i.e: minors under the age of 18, individuals not listed on the student's registration or consent to pick up form, an individual that has been removed from the student's registration per primary caregivers consent) *
I agree
I disagree
Late Pick Up Policy
A late pickup is anytime after the program end time. Specific program times are posted at your school location. All late pick ups will be documented as a written notice. 3 or more notices of late pick ups will result in termination of services

NOTE: We kindly request that parents/guardians cooperate with picking up your students on time. We understand that emergences arise. We also understand that traffic can be challenging or hectic, but expect all children to remain in the program for the required amount of time and be picked up on time. Traffic issues and family emergencies do not excuse the written notice of late pick up.
Late Pickup/No Show Procedures

In the event children are being picked up late, a designated staff member will remain with children until pickup by an adult that is authorized for student pickup.

This designated staff member will also do the following:
1. Contact parent or guardian at home, on his/her cellular phone or at work.
2. Contact persons that are listed on emergency contact information.
3. Contact supervisor to inform him/her that children are being supervised at the site after program hours.
4. Contact local authorities. *
I have read and understand
PARTICIPATION COMMITMENT

It is the responsibility of each family to adhere to all policies and procedures outlined in the Big Ideas Parent handbook.

AGREEMENT
1. Parent Participation Agreement: Each family MUST attend 3 scheduled Adult Family Member Events planned by Big Ideas Educational Services. These events may be attended by a parent/guardian, relative, or a family representative.
2 Program Time: Students must attend the after-school program daily and Sign out/dismissal is at 6:00 p.m.
3. Absences and Late/ Early Pickups. More than 3 absence (absent from school or not) in one month and/or early/late
pickups will result in dis-enrollment from the program

NON-COMPLIANCE
1. Parent Participation Agreement: Parents are responsible for fulfilling the participation agreement. Missing a scheduled Adult Family Member Event and student absences is a serious breach of the commitment parents make to the organization.
a. Students are required to attend the after-school program daily. Students are allowed 3 total absences monthly. On the 4th absence in one month the student will be removed from the after-school program.
b. The program staff will not accept any notice for absence (i.e. doctors note, parent notes, sick note, etc)
2. Program Time: Parent/guardian understands that this time commitment will ensure students receive the Program’s core components. Early dismissals (signing out before 5:30 p.m.) late pick-up (signing out after 6:00 p.m.) will result in removal from the after-school program.
*Excessive Late is pick-up after 6:10pm 3 or more total occurrences throughout the after-school year
3. Late Policy: After 3 late and/or early pick ups monthly student(s) will be removed from the program. Late pick up is 6:01p.m *
I have read and understand
I hereby authorize Big Ideas Educational Services, Inc. to receive information related to my child’s academic information, i.e. I.E.P. – If applicable, State Standardized testing scores and school grades as authorized by myself or my child’s principal and to use the same in determining an appropriate educational plan for my child. My child’s academic information may NOT be shared outside of Big Ideas for any reason unless such information is made anonymous. *
I agree
I disagree
This statement notifies parents that all student information given to Big Ideas Educational Services, Inc. will be secured (maintain in a locked/secure environment) at the end of each working day. It is also our responsibility to ensure that all computer records maintaining student information is held securely and appropriately protected. In addition, all information obtained will be kept confidential. *
Confirmed receipt of information
• Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

• Section 402.3125(5) F.S., requires that parents requires that parents receive a copy of the Child Care Facility Brochure, ”Know Your Child Care Facility” (CF/PI175-24) or

• Section 65C-20.11(20)(c) (1), F.A.C., requires that a parent(s) receive a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28).

• Section 65C-22.006(3)(c), F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility, or

•Section 65C-20.010(6)(c), F.A.C., requires that a written a copy of the family day care provider’s discipline policy be available for review by the patter(s). *
Confirmed receipt of information
I understand that family participation in ALL adult engagement activities are Mandatory. Family non-participation will result in dismissal of services. *
I agree
I disagree
TERMINATION

A family may be terminated from the program for the following reasons:
1. Failure to fulfill the participation commitment as outlined above.
2. Excessive student absents, early/late student pick-up
3. Physical and/or verbal abuse to staff or student by parent or child.
4. A child is enrolled in the program that has special needs which we cannot adequately meet with our current staffing plan.
5. If Big Ideas Educational Services deems it necessary to remove a family from the program, as defined in its policies and procedures, outlined in the parent handbook. *
I have read and understand
Miami Dade County Public School Disclosure

Dear M-DCPS Parent, It has come to our attention that you are interested in your child participating in Big Ideas Educational Services, Inc. It is important to understand that the organization Big Ideas Educational Services, Inc. is not organized, contracted, staffed and/or hosted by The School Board of Miami-Dade County, Florida. Any information that you are sharing is being done so through a third-party or private organization. Any forms that you are asked to complete are those of that third party organization and not that of M-DCPS. As a parent you should review these forms carefully as you may be waiving certain legal rights for you and/or your child. *
I have read and understand
Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.
Signature *
Clear
parent/guardian gave verbal consent for this form to be complete by a Big Ideas representative.
yes
no

STUDENT INFORMATION

PARENT/LEGAL GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

STUDENT HEALTH INFORMATION

HELP US GET TO KNOW YOUR CHILD

PARENT CONSENTS AND DISCLOSURES

Your signature below indicates that you have received the above items and that the information on this enrollment form is complete and accurate.