NUEVO COMIENZO COMMUNITY CENTER
Youth & Family Programs
Orosi High School Campus, Orosi, CA
Recruitment and Selection
Check-List
Adelante Latina, Los Guerreros and Xinachtli, and ElJoben Noble
Student Name: ____________________________________
The following list papers, that you should turn in before the 3rd week of class.
These papers are MANDATORY! This means you have to turn these papers in. Please turn them in as soon as possible. Below you can find the requirements we need to have in order for you to receive your check.
If the papers aren’t turned in on time, you will be deducted from your payment.
The requirements were as followed:
1. Permission from parents (Have all forms signed).
2. Copy of Recent Transcript/Report Card,
Programs for the Communities of Cutler, Orosi and Dinuba
Parent Permission Form
Congratulations! Your son or daughter ________________________ has been gladly accepted into the Adelante Latina/Los Guerreros/ Xinachtli/ El Joven Noble, they are EDUCATION AND PREVENTION programs. We are pleased to have her/him in our program, we are sure that he/she will be of great help along with the rest of the girl’s/boy’s. __________________________ will be attending an afterschool program.
Meetings for the girls and boys are held once or twice a week, on Mondays, Tuesday’s, Wednesdays, Thursday’s, or Friday’s. The girls/boys will come and get educated about tough touchy subjects that no one dares to ever talk about. Here in our Program, they will be educated about making proud choices, being proud of where they came from and being proud of who they are; along with other subjects. (See brochure for more details.)
We all know that talking about STD’s, Pregnancy, Sex, and Condoms etc. can be very difficult to talk about, especially with your sons/ daughters. Here in our Program, we make the girls /boys feel welcomed and safe every day in order for everyone to feel comfortable about the delicate topics.
This form is for the parent to sign to let us know that you have given your son/daughter permission to attend all weeks and all the sessions listed in the brochure. We would love to have every single boy/girl attend the program in order to receive the full education that we are providing them. Also in order to keep the classroom working smoothly and problem free we have created a “RULES, POLICY and CONSEQUENCES” page (You can find this attached to the packet) for your child. Please review these rules with you son/daughter.
I, _________________________, hereby permit my daughter/son ________________, to assist all sessions regarding the Adelante Latina/Los Guerreros/ Xinachtli/ EL Joven Noble, Programs and I agree to the “RULES, POLICY and CONSEQUENCES” page.
Cell: (559) 679-2808 Office: (559) 528-2846, Maria Diaz Program Leader Coordinator
Programs for the Communities For the Communities of Cutler, Orosi and Dinuba
Particpant Information
Name: _________________________ Age: ______ Date of Birth:______________
Address: __________________________________ Zip: __________ State: ____
Phone Number: _________________________________
Email Address: _________________________________
Medical Information:
Do you suffer from any kind of illness?
If so, please indicate: ____________________________
2. Any sort of allergies?
If so, please indicate: ____________________________
3. Are you currently taking any kind of medications?
If so, please indicate: ____________________________
Should we know anything else about your health that wasn’t listed above?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Parent/Legal Guardian: ____________________________________
Parent’s signature: _______________________________________________________
Emergency Contact and Follow up Form
For The Teen Pregnancy Prevention Program
Date: ______________
Please list contact information for three individuals who may be able to be contacted regarding treatment or those that could provide emergency assistance on your behalf should the need arise.
Contact # 1
Name: _____________________________________________________________
Address: ________________________________________________________ ___
Telephone No: ______________________________________________________
Relationship: ________________________________________________________
Contact # 2
Name: _____________________________________________________________
Address: ____________________________________________________________
Telephone No: ______________________________________________________
Relationship: _______________________________________________________
Contact # 3
Name: _____________________________________________________________
Address: ____________________________________________________________
Telephone No: ______________________________________________________
Relationship: _______________________________________________________
Follow Up: May we contact one or three individuals in case a satisfaction survey is conducted up to one year of discharge?
Yes: _____ No: _____
Parent’s signature: ____________________________________ Date: ____________
Parent Survey
1. Where were you born? __________________
If you were born in the U.S. what generation are you?
1st 2nd 3rd 4th 5th 6th 7th
2. Which of the following categories best describes your employment status?
- Unemployed, looking for work
- Unemployed, I'm not looking for a job
- By provisional contract (brigade, etc.)
- A part-time
- Full time employment
-Retired
- Disabled, unable to work '
-
Stay at home parent
3. What is your total family income per week? _________________________
4. What is your marital status?
Married / Widowed / Widowed - Single / Other:
5. In total how many members are in your family? __________________
RULES AND POLICY
ATTENDANCE
-
IF YOU MISS CLASS, YOU HAVE 3 CLASS DAYS TO PROVIDE A NOTE OR YOUR PARENTS CAN PROVIDE US WITH A CALL EXPLAINING THE ABSENCE. IF NO NOTE OR CALL IS PROVIDED YOU WILL NOT RECEIVE THE PAY FOR THAT MISSED DAY. IF YOU DO NOT HAVE A VALID EXCUSE FOR BEING ABSENT FOR A TOTAL OF THREE DAYS YOU WILL BE ASKED TO LEAVE THE PROGRAM FOR THIS CYCLE; YOU MAY RETURN DURING THE NEXT CYCLE.
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TARDIES: YOU NEED TO BRING A NOTE IN THE NEXT 3 CLASS DAYS EXPLAINING THE REASON OF THE TARDY. IF YOU DO NOT PROVIDE US WITH A NOTE, EACH THREE TARDIES WILL BE CONSIDERED AN ABSENCE
PAPERWORK
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ALL PAPERWORK MUST BE TURNED IN BY THE 3RD WEEK OR EVERY SESSION THEREAFTER YOU WILL BE COUNTED TARDY
CLEANING
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CLEANING: EVERYONE WILL BE GIVEN A TASK TO COMPLETE TOWARDS THE END OF THE SESSION; THE ROOM MUST LOOK CLEAN AND TIDY
Rules
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IF YOU ARE BEING DISRESPECTFUL TO ANYONE, RUDE, DISTRACTING PEOPLE FROM CLASS, TALKING BACK, HITTING OTHER PEOPLE, CURSING, BEING ON YOUR PHONE, AND NOT FOLLOWING THE GROUP RULES AND THE RULES ON THIS PAGE; THE FOLLOWING STEPS WILL OCCUR:
-
YOU WILL RECEIVE A WARNING
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YOU WILL NEED TO STEP OUTSIDE FOR 10 MINUTES
-
YOUR PARENTS WILL BE NOTIFIED OF YOUR BEHAVIOR AND YOU WILL NEED TO LEAVE FOR THE DAY AND YOU WILL NOT RECEIVE THE DAYS PAY
TLC/Nuevo Comienzo and Other Purposes
To Prevent Teen and Unplanned Pregnancy 2019-2050 TLC/Nuevo Comienzo and Other Purposes
Your statements and likeness (photograph, Video, interview, etc.) may be used by TLC/Nuevo Comienzo and other purposes to promote our activities in the media, for public presentations, on our websites, and in various publications or events. If you prefer that we don’t use your statements and/or likeness, please so indicate by checking the box below.
I consent to TLC/Nuevo Comienzo and other purposes to use my statements/ likeness in their materials including publications, newsletters, educations videos, presentations, and its website.
Print Student name: ________________________________________________________________________
Parents print name: _________________________________________________________________________
Parents signature if under age 18: _____________________________________________ Date: ___________
__________________________________________________________________________________________
LIABILITY WAIVER AND RELEASE FORM (MINOR CHILD)
THIS IS A RELEASE OF LEGAL RIGHTS — READ AND UNDERSTAND BEFORE SIGNING
I hereby certify that I am the adult parent or guardian of ______________________________, a minor child under the age of eighteen years, and I consent to his/her participation in recreational activities at TLC/ Nuevo Comienzo and its Youth Programs located at the Orosi High School 41815 Rd 128 Orosi CA, 93647 or at the Dinuba High School 340 E Kern St, Dinuba, CA 93618.
I understand and acknowledge that I am fully aware of and assume the risks (including but not limited to the risk of serious bodily injury, property loss or damage) of (1) said minor child’s participation in recreational activities at TLC/Nuevo Comienzo playing sports and (2) his/her use of TLC/ Nuevo Comienzo materials.
I understand that Nuevo Comienzo, the Dinuba or Cutler-Orosi Unified School Districts shall have no responsibility to pay for medical treatment and related costs if said minor child is injured.
Knowing the risks described above, I agree, personally and on behalf of the minor child named above, to assume all the risks and responsibilities surrounding my minor child’s participating in Nuevo Comienzo activities. To the fullest extent allowed by law, I hold harmless and agree to no indemnify, nor sue; TLC/Nuevo Comienzo, Dinuba, Cutler-Orosi Unified School District, its officers, directors, faculty, staff, volunteers, employees and agents, from and against any present or future claim, cause of action, loss or liability for injury to person or property, which said minor child may suffer or for which said minor child may be liable to any other person, related to said minor child’s participation in recreational activities at TLC/Nuevo Comienzo and its activities, resulting from any cause whatsoever, and regardless of fault.
I am at least eighteen years of age and have carefully read and freely signed this Liability Waiver and Release Form (Minor Child).
I understand and agree that no oral or written representations can or will alter the contents of this document.
Parent or guardian Name: _______________________________ Signature: _________________________________
Phone Number: ________________________
Emergency Contact name: _____________________________ Phone Number: _________________
School: ______________ Grade: ______________ School ID #: _________________ Date: __________
TLC/ Nuevo Comienzo Teen Pregnancy Prevention Programs
41815 Rd 128 340 E Kern St,
Orosi, CA 93647 Dinuba, CA 93618
559-528-2846 fax:559-528-4396 559-528-2846 fax: 559-528-4396
Sarahi Ovalle Site Manager
2021-2030 School Year
TLC/ Nuevo Comienzo Food Permission Slip
Student Name:______________________________________ School ID#:________
I give permission, as the parent/guardian of the student listed above, for my child to participate in various TLC/ Nuevo Comienzo celebrations/activities/group sessions involving food throughout the 2018-2020 school year.
Note: If there is a specific celebration/ activity you do not wish your child to participate in, please write a note to excuse him/her from the activity.
Students may be served the following food/drink items at these events:
Pizza (Cheese, Pepperoni, Sausage), Juice, Soda, Chips, Popcorn, Nachos, Ice Cream, Popsicles, Snow Cones, Cake, Brownies, Cookies, Cotton Candy, Cheesecake, beans, rice, salads, beef, chicken, pork and more.
Please list any food allergies your child has:
This permission slip must be signed in order for your child to be allowed to partake in any food or drinks served. Students will not be able to have food/drinks provided without a signed permission slip. This requirement is an effort to avoid possible food allergy reactions.
Parent Name (Printed) Parent Signature Phone Number
______________________ __________________________ _______________________