Beacons Program Registration

Register for Beacons

YWCA Beacon Learning Centers are located at two north Minneapolis schools, Hmong International Academy and Franklin Middle School.

They offer youth a combination of academic and enrichment activities four days a week. Beacon Learning Center afterschool and summer programs support school success, while providing opportunities for learning and leadership.

Fill out the form below to register for the Beacons Program at Franklin Middle School or Hmong International Academy for the 2020-2021 year.

Questions? For Beacons at Franklin, contact Aisha Wright at awright@ywcampls.org. For Beacons at HIA, contact Pheng Moua at pmoua@ywcampls.org or 612-668-2265.

About Beacons

Step 1 of 4

Parent/Guardian Information
Parent/Guardian Name*
First Last
Parent/Guardian Email*
Relationship to Student(s)*
Cell Phone
Home Phone
Work Phone
Parent/Guardian #2 Information
Parent/Guardian #2 Name
First Last
Parent/Guardian Email
Relationship to Student(s)
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone
Home Phone
Work Phone

Parent/Guardian Consent
Franklin
I agree:
- To allow YWCA Minneapolis to act on my behalf in case emergency medical care (applying first aid, contacting the child’s doctor) is needed for my child/ward.
- To allow my child to participate in online classes with YWCA Minneapolis staff or contracted employees.
- For medical personnel to act as judgment dictates in case emergency care is needed for my child/ward.
- That neither YWCA Minneapolis nor any person associated with YWCA Minneapolis program has any responsibility to me or my child/ward for any claims arising from any accident.
- That YWCA Minneapolis will not be held responsible in the case of sickness or injury of my child/ward while participating in any YWCA Minneapolis sponsored activity, or in transit to and from YWCA facilities, or on a field trip.
- To allow my child to ride in authorized YWCA vehicles.
My child has my consent to attend YWCA Beacons Program at Franklin Middle School.
HIA
I agree:
- To allow YWCA Minneapolis to act on my behalf in case emergency medical care (applying first aid, contacting the child’s doctor) is needed for my child/ward.
- To allow my child to participate in online classes with YWCA Minneapolis staff or contracted employees.
- For medical personnel to act as judgment dictates in case emergency care is needed for my child/ward.
- That neither YWCA Minneapolis nor any person associated with YWCA Minneapolis program has any responsibility to me or my child/ward for any claims arising from any accident.
- That YWCA Minneapolis will not be held responsible in the case of sickness or injury of my child/ward while participating in any YWCA Minneapolis sponsored activity, or in transit to and from YWCA facilities, or on a field trip.
- To allow my child to ride in authorized YWCA vehicles.
My child has my consent to attend YWCA Beacons Program at Hmong International Academy.
1. I grant permission for my child/ward: - To participate in all activities of YWCA youth programs - To participate in program field trips under proper supervision - To ride in authorized YWCA vehicles for program activities - For the YWCA Youth Program Counselor to obtain information on my child’s/ward’s academic and attendance records 2. I understand that programs may contain information on sexuality and other health-related issues and I give my child/ward permission to participate. 3. I agree that neither YWCA nor any other person associated with them has any responsibility to me or to my child/ward for any claims arising from accident, health or medical treatment. 4. I understand that any expenses incurred under item 3 will be the sole responsibility of the child’s/ward’s family. 5. I understand that YWCA staff and volunteers are Mandated Reporters. If abuse or neglect is suspected, YWCA staff and volunteers are required by Minnesota law and YWCA policies to place a report to Child Protection Services. 6. I hereby authorize YWCA staff to give my child/ward reasonable first aid and to transport my child/ward to a health care facility for emergency services as needed. I have read the above terms and agree to them while my child/ward is a participant in YWCA Minneapolis youth programs.*
1. I grant permission for my child/ward:
- To participate in all activities of YWCA youth programs
- To participate in program field trips under proper supervision
- To ride in authorized YWCA vehicles for program activities
- For the YWCA Youth Program Counselor to obtain information on my child’s/ward’s academic and attendance records

2. I understand that programs may contain information on sexuality and other health-related issues and I give my
child/ward permission to participate.

3. I agree that neither YWCA nor any other person associated with them has any responsibility to me or to my
child/ward for any claims arising from accident, health or medical treatment.

4. I understand that any expenses incurred under item 3 will be the sole responsibility of the child’s/ward’s family.

5. I understand that YWCA staff and volunteers are Mandated Reporters. If abuse or neglect is suspected, YWCA staff
and volunteers are required by Minnesota law and YWCA policies to place a report to Child Protection Services.

6. I hereby authorize YWCA staff to give my child/ward reasonable first aid and to transport my child/ward to a health care facility for emergency services as needed. I have read the above terms and agree to them while my child/ward is a participant in YWCA Minneapolis youth programs.
I agree to the following statements.
By typing my full name in the box below, I consent to the above. This is equivalent to my signature.*
Publicity Consent
- Make video and audio recordings of me and/or my voice. - Take and use photographs of me and/or my family. - Record, use, display and disclose in a video and/or other media intended for public consumption statements and/or information provided by me concerning myself and/or my family. - Use the activities listed above for direct mail, advertising, public relations, website, email, social media (e.g., Facebook, Twitter, etc.) and other online efforts related to the YWCA of Minneapolis. - Use my name and the names of members of my family in conjunction with the activities listed above. With respect to the above, I relinquish to the YWCA of Minneapolis all rights, title and interest I may have in all originals, edited versions, reproductions, and copies of any video and/or audio recording(s), prints, negatives, digital images and photographs in which my or members my family’s name, image, statements, information, and/or voice is used (the “Materials”). I also irrevocably grant the YWCA of Minneapolis permission to copyright, if applicable, the Materials, and to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the Materials in any manner and for any reason the YWCA of Minneapolis may deem proper, including the right to use the same for purposes of advertising or trade. By signing this Publicity Consent Release, I acknowledge that the YWCA of Minneapolis is not responsible for the unauthorized use of the Materials by unrelated third parties. I hereby release the YWCA of Minneapolis from liability for any damages that may arise from the unauthorized use of the Materials by a third party. NOTE: If you should no longer like the YWCA of Minneapolis to use your image in its awareness and education materials and activities, please contact the YWCA of Minneapolis. Due to the distribution and printing timelines, some of the materials the YWCA of Minneapolis may not be able to remove your image immediately from its pieces, but will do so as soon as those print pieces are scheduled for reprinting or new production. Print materials that are distributed to public audiences may not be recalled once distributed. Materials used for emails, website, social media or other online efforts may be removed from YWCA sites and networks, but due to the nature of the internet, may remain available online through other sources indefinitely.
- Make video and audio recordings of me and/or my voice.
- Take and use photographs of me and/or my family.
- Record, use, display and disclose in a video and/or other media intended for public consumption statements and/or information provided by me concerning myself and/or my family.
- Use the activities listed above for direct mail, advertising, public relations, website, email, social media (e.g., Facebook, Twitter, etc.) and other online efforts related to the YWCA of Minneapolis.
- Use my name and the names of members of my family in conjunction with the activities listed above.

With respect to the above, I relinquish to the YWCA of Minneapolis all rights, title and interest I may have in all originals, edited versions, reproductions, and copies of any video and/or audio recording(s), prints, negatives, digital images and photographs in which my or members my family’s name, image, statements, information, and/or voice is used (the “Materials”).

I also irrevocably grant the YWCA of Minneapolis permission to copyright, if applicable, the Materials, and to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the Materials in any manner and for any reason the YWCA of Minneapolis may deem proper, including the right to use the same for purposes of advertising or trade.

By signing this Publicity Consent Release, I acknowledge that the YWCA of Minneapolis is not responsible for the
unauthorized use of the Materials by unrelated third parties. I hereby release the YWCA of Minneapolis from liability for any damages that may arise from the unauthorized use of the Materials by a third party.

NOTE: If you should no longer like the YWCA of Minneapolis to use your image in its awareness and education materials and activities, please contact the YWCA of Minneapolis. Due to the distribution and printing timelines, some of the materials the YWCA of Minneapolis may not be able to remove your image immediately from its pieces, but will do so as soon as those print pieces are scheduled for reprinting or new production. Print materials that are distributed to public audiences may not be recalled once distributed. Materials used for emails, website, social media or other online efforts may be removed from YWCA sites and networks, but due to the nature of the internet, may remain available online through other sources indefinitely.
I hereby grant voluntarily and without monetary compensation the YWCA of Minneapolis permission to:
Name of Minor Child
Name of Minor Child
Name of Minor Child
By typing my full name in the box below, I consent to the above for the child(ren) listed. This is equivalent to my signature.
Date
Name
This field is for validation purposes and should be left unchanged.

Beacons Program Registration

Beacons Program Registration

Register for Beacons

Step 1 of 4

Student Information

Student #1

Student #2

Student #3

Parent/Guardian Information

Parent/Guardian #2 Information

Emergency Contact Information

Health Information

Parent/Guardian Consent

Publicity Consent