1

Participant Application 2017- 2018

524 Atkinson Street

Laurinburg, North Carolina 28352

Telephone: 910.852.5121

www.sandhillsdc.com

Please complete entire application and return to the above address.

2

Sandhills Development Center, Inc.

Application Packet Table of Contents

The following forms can be found within the application packet and

must be completed:

• Sandhills Development Center, Inc.*

• Participant Enrollment Form

• Personal Consent and Release Form

• Field Trip Permission Form

• Rules and Regulations

• Attendance Policy

• Emergency Contact Form

• Participant Identification Form

• Activities Schedule*

*These forms provide contact information for staff as well as details of program events.

Please remove these pages except for the signature pages.

3

Sandhills Development Center, Inc.

Sandhills Development Center, Inc. was founded by Robert Lamont

Smith, a Laurinburg native whom committed himself to providing resources

and opportunities to the youth of Scotland County. Robert recognized that

his community would benefit from free resources that would empower and

inspire our youth to positively contribute to the development of themselves,

communities, and society.

Sandhills Development Center, Inc. will provide academic and social

support to all participants involved in its After-School program (Mondays

and Thursdays; 4pm- 6pm), Restaurant Etiquette Experiences, In-State

College Campus Tours, Educational Day Trips, a Five-Week Summer Camp,

and an Annual Overnight Educational Trip. Transportation will be provided

unless otherwise stated.

Currently, Sandhills Development Center, Inc. is serving 5th to 8th

graders. All activities are free to participants and their families. Sandhills

Development Center, Inc. only requests that participants and their families

follow both the attendance and rules and regulations policies.

The after-school program will be held at 524 Atkinson St. in

Laurinburg, NC from 4 pm until 6 pm.

4

Please contact Calacia Douglas, Executive Director, at the following:

Primary Office Location and Hours

124 Cronly St.

Laurinburg, NC 28352

Tel. 910. 852. 5121

Monday- Friday 9am- 5pm (Except for Mondays and Fridays of after-school

program)

Email: Calacia.douglas@sandhillsdc.com

After-School Program

524 Atkinson St.

Laurinburg, NC 28352

Cell. 910. 373. 8443

Tel. 910. 266. 0092

Summer Program

Location: To Be Determined

Cell. 910. 373. 8443

Educational Trips

Calacia Douglas: 910. 373. 8443

E-Mail: Calacia.douglas@sandhillsdc.com

Check out our website for more event details at: www.sandhillsdc.com

5

Sandhills Development Center, Inc.

Participant Enrollment Form

2017-2018 __________________ ____________________________________________________________

Last Name First Name Middle Name

______________________________________________________________________________

Date of Birth Age Grade Gender Ethnicity

______________________________________________________________________________

Address City State Zip Code

______________________________________________________________________________

Parent/Guardian Name Telephone E-Mail

______________________________________________________________________________

Parent/Guardian Name Telephone E-Mail

______________________________________________________________________________

Employer Telephone

______________________________________________________________________________

Primary Care Physician Telephone

___________

T-Shirt Size

Please List any Allergies or Medical Conditions and Medications Administered:

________________________________________________________________________

________________________________________________________________________

6

Personal Consent & Release Form

Consent and Certification: I, the undersigned, being the parent or legal guardian of the

______________________________________, do hereby consent to the participation

of my youth in all the scheduled youth activities of Sandhills Development Center, Inc. ,

and any other supervised activities customarily associated with its youth group,

including youth rallies and overnight or weekend youth trips. Further, I certify that my

youth is physically fit and adequately prepared to participate in all recreational and

sporting events. If I wish to revoke this consent for any reason, I will promptly notify the

executive director in writing. Note to Parent: If giving consent for one activity only, or if

this consent is otherwise restricted, please specify:

________________________________________________________________________

________________________________________________________________________

Medical Treatment Authorization: I understand that I will be notified in the case of a

medical emergency. However, in the event that I cannot be reached, I authorize the

calling of a doctor and the providing of necessary medical services in the event that my

youth is injured or becomes ill. I authorize one or more of the following persons to make

emergency medical care decisions on behalf of my youth, if required by law or a health

care provider: ______________________________, ___________________________,

another adult chaperone designated by Executive Director, (Note to Parent: you may

add or delete a name as desired.) I authorize these persons to act in my place to consent

to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical

diagnosis or treatment, and hospital care. I understand that Sandhills Development

Center, Inc. will not be responsible for medical expenses incurred solely on the basis of

this authorization. I further agree to notify the executive director in writing of any

health changes that would restrict my youth’s participation in any normal youth

activities. I also understand that the executive director and designated adult chaperones

reserve the right to restrict my youth from any activity that they do not feel is within the

physical capabilities of my youth.

Permission for Treatment: My permission is granted for Sandhills Development Center,

Inc. staff or other adult(s) in charge to obtain necessary medical attention in case of

sickness or injury to my child. I, the undersigned, do hereby verify that the above

information is correct and I do hereby release and forever discharge all sponsors and

Sandhills Development Center, Inc. from any and all claims, demands, actions or causes

7

of action, past, present, or future arising out of any damage or injury while participating

in a Sandhills Development Center, Inc. sponsored youth activity.

_________________________________________________ ________________

Parent’s Signature Date

TRANSPORTATION RELEASE

I, _______________________________ give permission for youth to be transported to

and from Sandhills Development Center, Inc. sponsored activities in a company, rental,

or private vehicle.

DISCIPLINE RELEASE

Applies to participants only in the event of misconduct: I, _________________________

authorize the staff to send my student home at my expense.

PERSONAL BELONGINGS RELEASE

Applies to all traveling: I, _____________________________, realize that Sandhills

Development Center, Inc. or its sponsors are not responsible for personal belongings.

PHOTOGRAPHY & MEDIA RELEASE

I, ____________________________, give permission for my child,

__________________________, to have his/her picture taken for newspapers,

brochures, flyers, social media sites, and Sandhills Development Center, Inc. website.

GENERAL RELEASE

Applies to all traveling: The undersigned or a member of the immediate family of the

undersigned realizes that the participant may incur personal injury or bodily damage

while participating in such activities, and acknowledge that Sandhills Development

Center, Inc. , it’s officers, directors, employees, agents, or any other parties volunteering

on behalf of the organization, shall be held harmless from all actions, claims, costs,

expenses or damages of any kind, growing out of or related to any activities of the

organization. The undersigned or a member of the immediate family of the undersigned

further acknowledge this is a full and complete release for all injuries and damages

which the participant may sustain as a result of participating in any activity. I,

____________________________, being the legal guardian of

_______________________________ give my permission for him/her to participate in

Sandhills Development Center, Inc. sponsored activities.

8

I, ____________________________________, am signing on behalf of a minor (Please

print name) and certify that I am the parent or guardian of the minor and agree to the

consents and waivers, according to the paragraphs above, on behalf of this minor.

__________________________ ____________________________ _______________

Parent’s Printed Name Parent’s Signed Name Date

9

Sandhills Development Center, Inc.

After-School Transportation Consent Form

I,_________________________________, would like for my child, Parent/Guardian Name

_______________________________, to be picked up from Child’s Name

________________________________ each Monday and Thursday

dsfasfdsfdafdfdsfdsfdfddSchool Name

(excluding Holiday closures) and dropped off at ______________________. Home Address

I, ____________________, give permission for ______________________, Parent/Guardian Name School Name

to release my child/children (listed above) to Sandhills Development Center,

Inc. on Mondays and Thursdays to transport my child/children to their after-

school activity at dismissal time.

____________________________________ ________________ Parent/Guardian Signature Date

10

Sandhills Development Center, Inc.

Field Trip Permission Form

I, __________________________________________, authorize that my child,

_______________________________, has my permission to go on field trips offered by

Sandhills Development Center, Inc.

1. I have been informed of the details of this educational experience.

2. My child has my permission to participate in this supervised field experience.

3. I agree to instruct my child to obey all rules, regulations, and instructions given by

staff and/or authorized personnel. I further agree that no staff or authorized

personnel shall be held responsible or liable for injuries or other mishaps.

**Please attach a copy of your child’s health insurance card.

___________________________________ _________________ Parent’s Signature Date

11

Rules and Regulations of Sandhills Development Center, Inc.

Sandhills Development Center, Inc. has adopted the following rules and

regulations for the safety and protection of the participants, staff, volunteers,

personnel as well as the organization:

1. Bullying: Bullying is not permitted at Sandhills Development Center, Inc.

and will not be tolerated. In the event of bullying participants will be

unenrolled from the organization and prohibited from reenrolling in any

other programs that Sandhills Development Center, Inc. may offer.

2. Profanity/Cursing: Profanity is not acceptable under any circumstance. The

staff of Sandhills Development Center, Inc. are deserving of the utmost

respect as well as all participants.

3. Inappropriate Conversation/Behavior: Sandhills Development Center, Inc.

will not tolerate any sexual harassment of any kind, verbal or physical.

Violations may result in suspension or unenrollment of all participants

involved in the incident.

4. Disrespectful Behaviors towards Staff and Peers: Sandhills Development

Center, Inc. will not tolerate disrespect of any kind (verbal, physical, etc.)

towards any staff, volunteers, parents, etc.

5. Fighting: Sandhills Development Center, Inc. will not tolerate fighting,

kicking, spitting, hitting, biting, slapping, or any other kind of physical

aggression amongst participants or staff. Consequences will result in

suspension or unenrollment of the participant from Sandhills Development

Center, Inc.

12

Sandhills Development Center, Inc. expects each participant to abide by the

aforementioned rules and reserves the right to suspend as well as unenroll

any participant that violates any of these rules as well as other regulations

not specified above.

I, _______________________, understand that I am responsible for my

own actions. I agree that it is in my best interest to immediately contact a

staff member, volunteer, or another authorized adult if I feel unsafe,

threatened, or in danger. I understand that the consequences for

breaking any of the rules above include suspension or my unenrollment

from Sandhills Development Center, Inc.

________________________________ _______________ Participant’s Printed Signature Date

13

Attendance Policy

Sandhills Development Center, Inc. understands that each participant has

their personal obligations and is willing to overlook these absences.

However, Sandhills Development Center, Inc. believes it is for the

organization’s best interest if there is an attendance policy implemented.

After-School Program: Each participant will be able to miss 10 days of the

after-school program. Sandhills Development Center, Inc. will excuse the

following absences: doctor’s appointment, sporting events, practices,

holidays, and ceremonial events. Following absences, please present a note

for doctor’s appointments as well as extracurricular activities. If a

participant misses more than two consecutive weeks he/she will be

unenrolled from Sandhills Development Center, Inc.

Summer Program: Sandhills Development Center, Inc. will provide

transportation to and from the site. However, if the parents do not notify

the camp instructors or executive director of their absence more than twice

the organization reserves the right to unenroll the participant or revoke

transportation privileges.

Please note that all field trips are privileges and not guaranteed, Sandhills

Development Center, Inc. reserves the right to permit or prohibit

participants from attending field trips do to absences.

I, ___________________________, understand that it is my responsibility to

inform Sandhills Development Center, Inc. staff if my child’s involvement in

extracurricular activities or other events such as appointments will prevent

them from attending the after-school program, summer camp, or other

events. I understand that the presentation of notes may be necessary.

____________________________________ __________

Parent’s Signature Date

14

Participant Identification Page

*The following space will be utilized for a photograph of your child. Please provide the following information: _______ Hair color ________Height ________Weight Any Identifying marks, scars, etc:__________________________

PHOTO WILL BE PLACED HERE

15

Emergency Contact Form

Emergency Contact Information

Name Relationship Telephone Number

Telephone Number

Address