As a grant funded organization, we are required to report the data requested in this section. Please know that all information will be kept confidential, and receipt of this information is crucial to our ability to provide free programs for students on the North Shore.
Please name an adult other than parent/guardian
If you have any trouble completing this form, please contact Sarah Mascioli, smascioli@leap4ed.org, 617-545-4313 for Dream More or Taylor Mimms, tmimms@leap4ed.org, 978-595-2021, for Expanding Horizons.
- Massachusetts law requires any professionals (whether it is a doctor, teacher, etc.) whose work brings them in contact with children to notify DCF (Department of Children & Families) if they suspect that a child is being abused and/or neglected. - As afterschool program staff, anyone working at LEAP for Education (including volunteers and interns) is a mandated reporter.
Mandated reporters are required to break confidentiality whenever: - A minor reports being physically, sexually, verbally, and/or emotionally abused.- A mandated reporter suspects a minor is being abused and/or neglected- A minor reports intentions to hurt themselves or someone else- A mandated reporter suspects a minor is at imminent risk of possibly hurting themselves or someone else. Mandated reporters are legally responsible to take action under these conditions, including notifying proper authorities. We will use reasonable efforts to keep you informed of any actions that are taken. The rules of confidentiality are complicated and governed by numerous statutes and regulations. If you have any concerns regarding your rights it is best to seek legal counsel in advance of any program that includes mandatory reporters.
When my student participates in in-person programming, I authorize the Expanding Horizons summer program to carry out any service deemed necessary should an emergency occur. These measures may include administration of first aid and/or CPR by LEAP for Education staff, transportation to the nearest medical facility, and/or secure at the expense of the undersigned, appropriate medical treatment. I hereby release LEAP for Education, its employees and agents, from any and all liability or claims arising out of my student’s engagement in the above-described events.
If you answered “YES” to the 504 question above, do you give LEAP for Education Staff permission to access these documents or meet with teachers to better assist your student?
If you answered “YES” to the IEP question above, do you give LEAP for Education Staff permission to access these documents or meet with teachers to better assist your student?
Do you give permission for your student to participate in surveys and questionnaires which give feedback related to program outcomes? All information collected will be confidential.
I consent and give permission to LEAP for Education and those acting under its authority to use my child’s first name (not full name), photograph and/or likeness in connection with print, online, and video-based promotional materials for LEAP.
I give my student permission to go on local field trips that students walk to or take taxi rides to with program staff.
If you don’t have a cell phone, enter in 000-000-0000
Write none if this is not applicable