Page 1Page 2☟Page 3Page 4Page 5Page 6 AFTER SCHOOL APPLICATION New Castle County In Person You may only attend one session. Put a checkmark next to the dates you are interested in. Class 1 10/20/25 – 11/27/25Class 2 12/01/25 – 01/08/25Class 3 01/12/26 – 02/18/26Class 4 02/23/26 – 04/02/26Class 5 04/06/26 – 05/14/26 Class Registered: (Humanity’s Kitchen Use Only) First Name Last Name Social Security # (required) Race (required) American Indian or Alaskan NativeAsianBlack/African AmericanNative Hawaiian or other Pacific IslanderWhite/Causcasian Ethnicity (required) Hispanic or LatinoOther Gender (required) MaleFemaleAnother Gender Birthdate Email (required) Cell Phone Street Address: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Zip: Emergency contact: Relationship: Email: Cell Phone: Home Phone: Work Phone: High School: Last Grade Completed Are you currently enrolled? YesNo Do you meet the eligibility requirements? If not, please explain. Why would you like to attend this program? This program is funded by the Division of Vocational Rehabilitation, and students applying to the school must have some form of disability to be considered. You will be required to supply documentation of your disability such as an IEP, 504 Plan, Axis I-IV Diagnosis or documentation from a Doctor. What is your disability?: Transportation (please check one) BusCarParaTransitOther (someone will drop you off/pick you up/walk) Do you have a DVR Transitional Counselor? If so, provide name. Chef Jacket Size: SMLXL2X3X Applicants must: Eligibility Requirements 1. Be between the ages of 14 to 21. 2. Not be a danger to self or others. 3. Be available to be in the classroom from 5:30pm to 7:30pm Monday thru Thursday for six weeks. 4. Must be enrolled in high school. 5. Be curious, and ready to learn. 6. Able to stand up to 2-4 hours daily with or without reasonable accommodation. Exceptions can be made on a case-by-case basis. 7. Able to attend class every day on time. 8. No violent or sexual criminal history. (This means murder, or on sex offenders list) 9. Students must have a documented disability and documents such as an IEP, 504 Plan, Psychological with Axis I-IV diagnosis, physicians letter and/or be potentially eligible for DVR Services. Please read the above criteria carefully. If you are able to meet these criteria, please sign and date below. Please use the cursor on the mouse to sign Signature of student (required) Date: (required) ACKNOWLEDGMENTS: I hereby affirm that my answers to the foregoing questions are true and correct... Student Signature:(required) Date:(required) Parent or Guardian Signature if under the age of 18:(required) Date:(required) Humanity's Kitchen - Camp Health/Consent Information Youth's Name Medications (prescription and over the counter) your youth currently takes... Youth's Physician Phone # Youth's Dentist Phone # Insurance Policy # Group # Carrier Name of Responsible Party on Medical Insurance Card: DATE OF LAST: Tetanus Shot MMR Diphtheria Please initial indicating that all immunizations are up to date Parent Initials (required) Student Pick Up Authorization I, (Parent/Guardian name), give the following person(s) permission to pick up my child. Person 1 First Name Last Name Relationship to student Cell Number Person 2 First Name Last Name Relationship to student Cell Number My child will be taking public transportation. Parent/Guardian Initials (required) Date: (required) *** I hereby release Humanity's Kitchen and all employees from any and all claims, actions, and liability relating to my child’s transportation, including picking my child up from school. Parent/Legal Guardian's PRINTED NAME: Parent/Legal Guardian's Initials:(required) NOTE: All students must be picked up promptly at 6:00 pm. Students picked up after 6:15 pm risk being released from the program. Parent Statement of Understanding The following information is important for the safety and protection of your child. Please read and sign below. I understand my child will not be released to any person(s) not listed on the enrollment form. I understand my child will not be released to any person(s) under the influence of drugs or alcohol. I understand I am not to leave my child unless an HK staff member or volunteer is there to receive and supervise. I understand I must sign my child in/out each day. I understand HK must report suspected abuse/neglect. I understand HK staff/volunteers cannot babysit or transport children outside the program. I have read and understand the statements above regarding Humanity’s Kitchen policies and procedures. Parent/Guardian Initials (required) Date:(required) Behavior Agreement At Humanity’s Kitchen we take the happiness of your children very seriously... Below is our Behavior Agreement. I will listen to the staff and follow their directions. I will respect other people's belongings. I will not hit or fight others. I will use appropriate language and positive attitude. I will ask permission before leaving the building. Student Initials (required) Date:(required) Parent/Guardian Initials (required) Date:(required) Humanity’s Kitchen PARTICIPANT WAIVER FORM ACKNOWLEDGEMENT I expressly acknowledge there are certain risks and personal injuries inherent in participating in Humanity’s Kitchen programs... I hereby release Humanity’s Kitchen from any and all claims arising from such participation. RELEASE In consideration of participation, I waive, release, and forever discharge Humanity’s Kitchen from any and all claims, losses, or injuries to person or property arising from attendance or participation in activities, except for gross negligence or willful misconduct. INDEMNIFICATION I agree to indemnify and hold harmless Humanity’s Kitchen from any and all claims, losses, costs, and expenses resulting from participation in programs by me or my child. ACCEPTANCE I acknowledge and agree to the terms set forth on this Participant Waiver Form. Initials of Participant (required) Date:(required) Initials of Parent/Guardian (under 18) (required) Date:(required) Please attach the first page ONLY of one of the following documents: IEP, 504 Plan, Axis-I-IV diagnosis or physician letter. (JPEG, PDF or Word Document only) Tabs Powered by WordPress Post Tabs Pro Plugin Δ
