SUSPENDED FORM

This is an online version of the ETAP - Application. There is information that will need to be entered more than one time. You will, however, have the option to preview the form before final submission and you can save the form at any time and finish it later.

Date:

City:

Property:

Eden Technology Access Program or ETAP is open to young people between the ages of 14 and 19. ETAP Trainees receive education in the areas of technology, tech support, video work, and youth leadership development. Service Crew Get the same education and have an opportunity to teach what they have learned to others.

Applicant Information

My Name:

My Address:

My Date of Birth:
Use the date picker and click on the year to select the birth year

My Age:

I am in grade:

Or I am attending: College

Or other:

My Cell Phone

My Email

Parent/Guardian(s) Name:

Parent/Guardian(s) Name 2:

Parent/Guardian(s) Phone:

Parent/Guardian(s) Phone 2:

Parent/Guardian(s) Email:

Parent/Guardian(s) Email 2:

Emergency Contact (Different than Parent or Guardian)

Emergency Contact Name (if Parent/Guardian can’t be reached):

Emergency Contact (Phone):

Emergency Contact Name (if Parent/Guardian can’t be reached) 2:

Emergency Contact (Phone) 2:

I
Enter your full name

declare that the above information is true, and that I understand that the application committee will accept or reject my application based on this information.

Applicant Signature

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Parent/Guardian Signature

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Eden Technology Access Program - ETAP Application last updated on 9/16/2015

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Eden Housing Resident Services, Inc.

Eden Technology Access Program - ETAP

Medical Consent Form

Child's Name:

Age:

Birth date:
Use the date picker and click on the year to select the birth year

Address:

Home Phone #:

Adults Living with Participant:

Name:

Relationship:

Phone #:

Name:

Relationship:

Phone #:

Emergency Contacts: In case of an emergency, we always try to contact the parent or guardian first. In the event a parent/legal guardian cannot be reached, we need to be able to contact at least 2 other friends or relatives.

1. Name
Required

Relationship

Phone #

2. Name
Required

Relationship

Phone #

3. Name

Relationship

Phone #

Medical History: This information will be kept confidential, except in cases of emergency, at which point it will be shared with the necessary medical personnel.

If there has been any history of the following, please check where necessary:

If selected please indicate below:

Food Allergies

If selected please indicate below:

Medicine or other Allergies

Food Allergies:

Medicine or other Allergies:

Medications Taken Daily:

Chronic/Recurring Illness:

Family Doctor:

Phone #

Preferred Hospital:

Family Dentist:

Medical Insurance Company:

Policy:

ETAP: Page 1 of 2

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Personal Information:

Should there be any restrictions/concerns on your child's activities?

Select one:

Yes‎ No‎

If yes, please explain

Authorization:

I hereby authorize Eden Housing Resident Services, Inc. (EHRSI), Eden Housing Management, Inc. (EHMI), its delegated leaders, directors, Property management site staff, Computer Learning Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners to consent to any medical and hospital care to be rendered to the above child upon the advice of a licensed physician. It is understood that is time and circumstances, reasonably permit, EHRSI, EHMI, Eden Housing Inc. subsidiaries, and/or service provider partners will attempt, but are not required, to communicate with me or emergency contacts designated prior to treatment. The undersigned further agrees that, EHRSI, EHMI, its designated leaders, directors, Property management site staff, Computer Learning Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners, are not legally or financially liable for any claim arising from any consent given in good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment of the above child is given to EHRSI, EHMI, Property management site staff, Computer Learning Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners, in conjunction with an authorized event.

Parent/Guardian Signature:

Clear

Date:

ETAP: Page 2 of 2

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Acceptable Use Policy

Eden Housing Computer Learning Centers

Computer and Internet resources are made available to Eden Housing residents through the Computer Learning Center. The purpose of this center is to assist residents with computer assisted leaming and in enrichment activities. Use of this center's resources is a privilege, not a right; and requires that all who use the center, respect property, staff and other users. Failure to do so may result in punitive action(s) listed below. Property management site staff, Computer Leaming Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners, will determine what "acceptable use" is and their decision is final. Below are guidelines for determining acceptable use:

The Computer Learning Center is a safe place for any and all residents to pursue learning and enrichment activities. Positive behavior is expected. Computer Learning Center users conduct themselves respectfully, safely and responsibly in both words and actions. Behavior, including verbal behavior, which belittles, threatens or otherwise disrupts the legitimate activities of center users, is not tolerated.

The Computer Learning Center contains hardware, software, books and other materials, which are the property of Eden Housing Resident Service, Inc. Damage, theft or unauthorized modification of these materials is not acceptable. Users will be held liable for damage. In general, software belonging to residents may not be used in the center. Copying the center's software is illegal and may lead to, loss of center privileges, fines, imprisonment, lease violations up to and including evictions.

The Computer Learning Center provides access to the Internet as a shared resource in a public place. All users must understand that nothing they do using the center's computers or Internet (including e-mail) is private. The use of private information such as credit card numbers and important passwords is discouraged for your safety. Behavior, which may be considered acceptable for adults on their private computers, may not be considered appropriate in the center. Property management site staff, Computer Learning Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners, may periodically monitor for inappropriate use.

The Computer Learning Center reserves the right to change its policies at any time. Neither The Computer Learning Center, nor Eden Housing Resident Services, Inc. make any warranties (expressed or implied) with respect to Internet service and assumes no responsibility for:

• The content of any advice or information received by a user or any charges incurred as a result of seeking or accepting such advice;
• Any costs, liabilities or damages caused by the way the user chooses to use his/her Internet access through the Center;
• Any consequences of service interruptions or changes, even if the disruptions arise from circumstances under the control of The Computer Learning Center, or Eden Housing Resident Services, Inc. These services are provided on an as is, when available basis.

Address:

Names and Signatures of all residents living at address above (Use paper form for more signatures if necessary)

(Print)

Electronic signature

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(Print)

Electronic signature

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(Print)

Electronic signature

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(Print)

Electronic signature

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(Print)

Electronic signature

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*In addition, you should also be aware that the Property management site staff, Computer Learning Center staff, Eden Housing Inc. subsidiaries, and/or service provider partners, reserves the right to dismiss any user for inappropriate use or abuse of the Computer Learning Center for an appropriate amount of time. The unit may receive lease violations up to and including evictions, for misconduct in the lab.

Last updated 9/10/2015

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www.edenhousing.org

22645 Grand street
Hayward, CA 94541

510.5821460 Phone
510.582.6523 Fax

I
Write your full name

give my permission for Eden Housing, Inc. and its subsidiaries to use photographs, images, or any media of me and/or my children under 18 years of age (listed below) for fundraising purposes and promotion of Eden Housing's developments, services, and Eden Housing's ffiliates. The photograph may or may not be used in our publications, podcasts, ideos, and our website at www.edenhousing.org or at our affiliates publications, odcasts, videos, and websites.

I hereby release Eden Housing, Inc., its directors, officers, employees, affiliates, agents, successors and assigns from and against any and all claims, demands and actions of every kind that may arise as a direct or indirect result of the above use of my personal stories, photographs, and recorded audio and video footage.

This release is made with the full intention of binding myself, my spouse, heirs, legal representatives and assigns.

Signed,

Clear

Name:

Address:

Phone:

Date:

Children's Names and Ages
Please list all children and their ages.

Eden Housing does not discriminate based on race, color, religion, sex, handicap, familial status, national origin, or any other arbitrary basis. TDD/TTY 1.800.735.2922