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Tutoring Program

A guardian or a parent’s cancer diagnosis significantly impacts their children’s educational journey, often leading to increased emotional stress, anxiety, and distractions that hinder academic performance. This program is specifically designed to support students facing these challenges by offering tailored educational resources and emotional assistance. By empowering these students, the program fosters resilience and academic success, helping them navigate their family circumstances and preparing them to become the next generation of leaders who can thrive despite adversity.

Step 1 of 3

Student Information

Name

First Last

Does the student have a learning disability?

No

Yes

Name of disability

Grade

Gender(Required)

Boy

Girl

Date of Birth(Required)

How did you hear about this program?(Required)

Home Room Teacher(Required)

Subjects

Maths

ELA

NShelter Parental/Guardian Consent Form

Tutoring Sessions for Children of Parents Affected by Cancer

1. General Information

I, the undersigned parent/guardian, hereby give permission for my child to participate in the tutoring program facilitated by NShelter at the local library chose on the registration form. I understand that this program is offered free of charge to children whose parents or guardians are affected by cancer, and is conducted by university students and retired school teachers volunteering their time to provide academic support.

2. Program Overview

The tutoring sessions will take place in a designated conference room at the local library during after-school hours. The program may cover a variety of academic subjects, and sessions are designed to support students in achieving their educational goals. The specific schedule will be arranged between NShelter and myself, with consideration of my child’s availability.

3. Permission for Participation

I understand that:

Participation in the program is voluntary, and I may withdraw my child at any time by notifying NShelter.
My child will be attending the sessions under the supervision of qualified tutors and volunteers.
While the program aims to enhance my child’s learning experience, I acknowledge that NShelter does not guarantee any specific academic results.

4. Consent to Contact and Scheduling

I agree to provide accurate contact information and understand that Nshelter may contact me via phone, email, or other methods to:

Confirm or modify session schedules.
Discuss my child’s academic progress.
Notify me of any issues, emergencies, or changes in the program.

I agree that my child will be available for the scheduled tutoring sessions and will notify Nshelter in advance if my child cannot attend a session.

5. Transportation Arrangements

I understand that I am responsible for transporting my child to and from the tutoring sessions, or arranging safe and reliable transportation NShelter and the library are not responsible for any incidents that occur during transportation to and from the sessions.

6. Health Information and Emergency Contact

I agree to provide any relevant health information about my child that may be necessary for the tutors to know, such as allergies, medical conditions, or special needs. In the event of a medical emergency, I authorize NShelter to seek necessary medical treatment for my child.

7. Consent to Use of Photos or Videos

I understand that photos or videos of the tutoring sessions may be taken for promotional purposes (e.g., on the organization’s website or social media). I hereby give my consent for my child to be photographed or recorded during program activities for these purposes. (Please check the appropriate box below.)

I consent to the use of photos/videos of my child for promotional purposes.

8. Code of Conduct

I understand that my child is expected to behave respectfully and adhere to the program’s code of conduct, as well as the rules set by the library. If my child fails to comply with these rules NShelter reserves the right to remove my child from the program.

9. Consent and Acknowledgment

I, the undersigned parent/guardian, acknowledge that I have read and understood the terms outlined in this Consent Form. I agree to allow my child to participate in the tutoring program, and I understand the expectations and responsibilities set forth herein.

NShelter Liability Waiver and Release Form

Effective Date: [Date of Signature]

Program Name: Tutoring
Location: Oconee County Library / Central Pickens Library
Tutoring Sessions for Children of Parents Affected by Cancer

This Liability Waiver and Release Form is entered into by the undersigned parent/guardian (“Participant”) and Nshelter (“Organization”) as a condition of participation in the tutoring program provided at the library chosen on the registration form and facilitated by NShelter.

1. Acknowledgment of Risks

I, the undersigned parent/guardian, acknowledge and understand that my child’s participation in the tutoring program involves inherent risks, including but not limited to:

Personal injury or accidents that may occur during tutoring sessions or while on library premises.
Emotional or psychological stress related to tutoring or educational activities.
Risks associated with transportation to and from the tutoring sessions (if applicable).

2. Assumption of Responsibility

I, on behalf of myself and my child, voluntarily assume all risks associated with my child’s participation in the tutoring program. I understand that these activities are provided free of charge by [Organization Name], and that my child’s participation is purely voluntary.

3. Waiver and Release of Liability

In consideration of NShelter allowing my child to participate in this program, I hereby release, discharge, and hold harmless Nshelter its employees, volunteers, agents, and representatives from any and all claims, actions, demands, or liabilities that may arise in connection with my child’s participation in the tutoring program, including but not limited to:

Injury, illness, or death arising out of participation.
Loss or damage to personal property.
Any other incident that may occur during participation in the program, whether arising from negligence or otherwise.

This waiver and release extend to [Library Name], its employees, agents, and representatives.

4. Medical Emergency Authorization

In the event of a medical emergency, I authorize NShelter and its representatives to take any necessary action to provide emergency medical treatment to my child, including calling emergency services or taking my child to a medical facility. I understand that any medical costs incurred will be my sole responsibility.

5. Agreement to Follow Program Guidelines

I understand that my child is required to adhere to the guidelines and policies of NShelter and the library hosting the tutoring program. Failure to comply with the rules may result in the dismissal of my child from the program.

6. Governing Law

This Liability Waiver and Release shall be governed by the laws of the State of South Carolina. Any disputes arising from this agreement shall be subject to the exclusive jurisdiction of the courts in [City/ Oconee County], South Carolina.

7. Parental/Guardian Consent and Acknowledgement

I certify that I am the parent or legal guardian of the minor named below and that I have the legal authority to execute this Waiver and Release Form on behalf of my child. By signing this document, I acknowledge that I have read and fully understand its contents and agree to its terms.

8. Signature

NShelter Code of Conduct Agreement

Effective Date: [Signed Date]

Program Name: Tutoring Program Location: [Library Name and Address as chose on the registration form] Tutoring Sessions for Children of Parents Affected by Cancer

NShelter is committed to providing a safe, respectful, and productive environment for all participants, including students, tutors, and volunteers. The following Code of Conduct outlines the expectations for behavior during the tutoring sessions. By signing this document, all participants agree to abide by these guidelines.

1. General Expectations for Students

As a participant in the tutoring program, I understand that:

Respect for Others: I will be respectful towards all tutors, volunteers, library staff, and fellow students. Bullying, teasing, or disrespectful behavior will not be tolerated.
Punctuality and Attendance: I will arrive on time for all scheduled tutoring sessions. If I am unable to attend, I will notify NShelter or the tutor in advance.
Focus and Participation: I will actively participate in the tutoring sessions, pay attention, and put in my best effort. Disruptive behavior or lack of cooperation will result in a warning, and repeated issues may lead to dismissal from the program.

Use of Library Space: I will respect the library’s property, follow all library rules, and use the facilities in a responsible manner. I will not damage library property, and I will help keep the space clean.

Electronic Devices: I will not use my phone or any electronic device during tutoring sessions unless it is required for academic purposes or with the tutor’s permission.Dress Code: I will wear appropriate clothing to the tutoring sessions that is neat, clean, and suitable for an academic environment.

2. General Expectations for Tutors and Volunteers

As a tutor or volunteer in the tutoring program, I agree to:

Professionalism: I will treat students, parents/guardians, and library staff with respect and professionalism at all times. I will refrain from any form of discrimination or harassment.
Preparation and Punctuality: I will arrive on time for all tutoring sessions and come prepared with the necessary materials and resources to assist students. If I am unable to attend a session, I will notify NShelter in advance and ensure proper coverage for the session.
Positive Learning Environment: I will foster a positive and inclusive learning environment, providing support, encouragement, and guidance to the students. I will be patient and considerate in addressing their academic needs.
Boundaries and Safety: I will maintain appropriate boundaries with all students and avoid any inappropriate behavior. I will report any concerns regarding student safety to NShelter or the appropriate authorities.
Confidentiality: I will maintain the confidentiality of student information and not share any details about students’ academic performance, personal information, or participation without parental/guardian consent.

3. Discipline and Behavioral Issues

First Warning: If a participant violates any part of this Code of Conduct, they will receive a verbal warning from the tutor or program administrator.
Second Warning: If the behavior continues, a second warning will be issued, and the parent/guardian will be contacted to discuss the issue.
Dismissal: If the behavior persists after the second warning, NShelter reserves the right to remove the participant from the program.

4. Zero-Tolerance Policy

The following behaviors will result in immediate dismissal from the tutoring program:

Violence or Threats: Any form of physical violence, aggressive behavior, or threats toward tutors, volunteers, students, or library staff.
Bullying or Harassment: Engaging in bullying, harassment, or discrimination against any individual based on race, gender, religion, sexual orientation, or any other protected characteristic.
Substance Use: Possession or use of alcohol, drugs, or other illegal substances during the tutoring sessions or on library property.

5. Agreement and Acknowledgement

By signing this document, I acknowledge that I have read and understood the Code of Conduct for NShelter’s tutoring program. I agree to abide by these rules and understand that failure to comply may result in my removal from the program.

Student Acknowledgment

Student Name: __________________________________
Student Signature: __________________________________
Date: __________________________________

Parent/Guardian Acknowledgment

Parent/Guardian Name: __________________________________ Parent/Guardian Signature: __________________________________
Date: __________________________________

Tutor/Volunteer Acknowledgment

Tutor/Volunteer Name: __________________________________ Tutor/Volunteer Signature: __________________________________
Date: __________________________________

Visitation Guidelines Policy and Agreement

Scheduling: Visitations are scheduled seven business days after the request is submitted. We understand the urgency of some situations and will make reasonable accommodations whenever possible.
Recommended Presence: While not mandatory, we strongly recommend the presence of a family member or caregiver during our visit to provide support and ensure the comfort of the patient.
Visitation Days and Hours: Visitations are scheduled for Thursdays and Saturdays between noon and 6 pm. However, we are willing to adjust visitation times based on the specific needs and policies of the healthcare facility.
Hospital Policies: We will adhere to the visitation policies of the healthcare facility, including any restrictions or limitations they may have in place.

Legal Protections:

The visitation form must be filled out accurately and completely by a surrogate or proxy if applicable.

Confidentiality, Privacy and Terms:

1. Hospital Regulations

The requester must share any relevant hospital regulations or requirements with our representative prior to the visit.

2. Escort Requirement

For the safety and privacy of the patient, the requester must arrange for a family member or caregiver to meet our representative at the front office and escort them to the patient’s room.

3. Patient Privacy

The requester must inform us of any specific privacy concerns or restrictions related to the patient’s condition or treatment.

4. Health Precautions

While we strive to maintain a safe environment, we are not responsible for any damage to medical equipment or the spread of infections. Our representatives will wear masks during visitations to minimize any potential risks.

5. Emergency Contact Information

The requester must provide at least two emergency contact persons, including their full names, relationship to the patient, phone numbers, and any relevant medical information.

6. Visitor Conduct

Visitors are expected to behave respectfully and responsibly during the visitation. This includes following all hospital rules and regulations, maintaining a quiet and calm demeanor, and refraining from disruptive behavior such as loud conversations or arguments.

Any behavior that disturbs the peace or compromises the safety and comfort of the patient, other visitors, or hospital staff may result in the immediate termination of the visitation.

7. Visitor Identification

All visitors must present valid photo identification upon arrival at the healthcare facility. This identification will be verified by hospital staff or security personnel before granting access to the patient’s room.

Visitors should also be prepared to provide the name of the patient they are visiting and any other relevant information requested by hospital staff.

8. Visitor Limitations

The number of visitors allowed during a single visitation may be limited based on the patient’s condition, the size of the patient’s room, and the hospital’s visitation policies.

In cases where visitor limitations apply, priority may be given to immediate family members or caregivers.

9. Visitor Health Screening

Visitors may be required to undergo health screenings before being allowed to enter the healthcare facility. This may include temperature checks, symptom assessments, or other screening measures deemed necessary by hospital staff.

Visitors who exhibit symptoms of illness or who have been exposed to contagious diseases may be asked to postpone their visitation until they are no longer at risk of spreading infection.

10. Visitor Age Restrictions

Visitors under the age of [insert age limit] must be accompanied by an adult at all times during the visitation.

Children should be supervised closely to ensure their safety and to minimize disruptions to the patient and other visitors.

11. Photography and Recording

Photography and recording devices, including smartphones, cameras, and audio recorders, may not be permitted during the visitation without prior authorization from the healthcare facility and the patient or their legal representative.

Any requests to take photographs or record audio or video during the visitation must be approved by hospital staff and the patient’s attending physician.

12. Cancellation Policy

If the requester needs to cancel or reschedule a visitation, they must notify Nutifafa Shelter as soon as possible to make appropriate arrangements.

Failure to provide sufficient notice of cancellation may result in delays or difficulties in scheduling future visitations.

13. Liability Waiver

By signing this agreement, the requester agrees to release Nutifafa Shelter, its officers, directors, employees, volunteers, and agents from any liability for injuries, damages, or losses that may occur during the visitation, except in cases of gross negligence or willful misconduct.

This waiver of liability extends to any claims arising from accidents, injuries, illnesses, property damage, or other incidents that occur during the visitation, whether caused by the actions or omissions of Nutifafa Shelter or any third parties involved.

14. Feedback and Evaluation

We welcome feedback from patients and their families regarding their experience with our visitation services. Feedback can be submitted via email to cancercare@nshelter.org or through our website.

Feedback may include suggestions for improvement, compliments for exceptional service, or concerns about any aspect of the visitation process. All feedback will be reviewed and considered by Nutifafa Shelter’s management team to inform future decisions and improvements.

15. Termination of Agreement

Nutifafa Shelter reserves the right to terminate this agreement at any time if the terms and conditions outlined herein are violated or if deemed necessary for the safety and well-being of the patient, our representatives, or others involved.

In the event of termination, Nutifafa Shelter will notify the requester or their designated representative as soon as possible and provide an explanation for the termination, if feasible.

Any outstanding visitation requests or scheduled appointments may be cancelled or rescheduled at the discretion of Nutifafa Shelter.

16. Governing Law

This agreement shall be governed by and construed in accordance with the laws of the State of South Carolina, without regard to its conflict of law provisions.

Any disputes arising out of or related to this agreement shall be resolved exclusively through the courts of the State of South Carolina, and the parties hereby consent to the jurisdiction and venue of such courts.

Contact Information: For any queries related to visitation or to report any issues or concerns, please contact us at cancercare@nshelter.org.

By clicking this box, I agree to the terms and conditions outlined in this Hospital Visitation Policy and Agreement.
By signing this agreement, the requester acknowledges that he/ she has the legal authority to request visitation on behalf of the patient, if applicable