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ACSF Summer Camp Release Form 2025

Please complete all fields and provide a valid email address.
Families in-need may receive discounted rates for Summer Camp through our (RAY) Reaching All Youth program. If interested, please select "yes" below and we will be in touch with details.
(mm/dd/yy)
Summer Camp Sessions - Please Check Camp Choice (s)
* Discounts are available for siblings and multiple camps.
* Discounts are available for siblings and multiple camps.
Please provide following information for the parent(s) or caregiver(s) the youth live with:
If the home address is different from the one provided above, please include it below:
Primary Phone
Home address if different from above:
Emergency Contact Name: (First and Last Name)
Relationship to Child:
Phone Number:
Medication(s):
IT IS SUGGESTED THAT ALL STAFF AND STUDENTS BE VACCINATED AGAINST COVID-19
We strongly recommend that everyone keep their Covid-19 vaccinations up to date. While masking is optional, we ask that all students remain mindful of the health risks. If you experience any cold or flu symptoms, please stay home to protect others. Please let us know if you are vaccinated by listing your vaccination dates.
Vaccination Date
Vaccination Date
Vaccination Date

By checking the box below, I, the undersigned, agree to the following terms and conditions for my child’s participation in activities with ABADÁ-Capoeira San Francisco (ACSF):

I hereby give permission for my child to be photographed, videotaped, and/or interviewed for ABADÁ-Capoeira San Francisco (ACSF) in promotional materials.
I hereby give permission for my child to participate in scheduled activities that occur off-site at nearby facilities (e.g., parks, playgrounds, etc.). I understand ACSF staff will supervise all activities, including traveling to and from the studio to the off-site location.
Participation is contingent upon students following ACSF’s expectations and exhibiting positive behavior. Students who do not follow these guidelines may be suspended or removed from the Summer Camp program without refund of enrollment fees.
I understand that I will be sent important rules for safety and will go over them with my child to ensure they are understood and followed. I accept that there are potentially serious risks and dangers inherently associated with the activities, and I know it is important that no students do anything they consider unsafe. I have instructed my child accordingly. ACSF directors and staff work to ensure the safety of participants and are trained in first aid techniques and to follow established emergency procedures. I understand that there may still be risks and dangers beyond their control, and I accept full responsibility for any losses or damages to me or my child, however caused or alleged to be caused. I intend my signature to be a complete and unconditional release from liability to the full extent allowed by law.

The San Francisco Department of Children, Youth, and Their Families (DCYF) funds our agency and the services we provide. To fulfill the requirements of this funding, we share information about the participants in our services with DCYF. DCYF and the San Francisco Unified School District (SFUSD) maintain a shared, secure database to record information about services provided to San Francisco youth by DCYF’s grantees in order to facilitate outreach and enrollment, and track program use and impact. As a DCYF grantee, our agency has access to this shared database to both see and report data about the youth we serve. The data that we report to DCYF is also shared with SFUSD.

1) Our agency to share information about your child’s participation in our program (or your participation, if you are 18 years of age or older) with authorized staff at DCYF and SFUSD for the purposes described above.  The information that our agency reports to DCYF includes:

  • Personal information, such as name, date of birth, and address;
  • Demographic information, such as race/ethnicity and gender identity;
  • Education information, such as school name and grade level;
  • Participation in activities and services, such as dates of attendance and hours attended;
  • Anonymous and voluntary youth experience surveys.

2) SFUSD to share certain information about your child (or you, if you are 18 years of age or older) with authorized staff from our program as a DCYF grantee. The information that SFUSD reports to DCYF includes:

  • Personal information, such as name, date of birth, and address;
  • Education information, such as school name and grade level;
  • Dates of attendance in SFUSD or an SFUSD school.

3) Confidentiality and Data Use:
DCYF, SFUSD, or our agency will not publicly report any information that we provide in a way that may be used to identify your child (or you, if you are 18 years of age or older).

4) Restrictions:
All information related to an SFUSD student is protected by federal and state laws that govern the use, disclosure, and re-disclosure of student education records. No party other than DCYF, SFUSD, and our agency will have access to personally identifiable information reported into the database, except where the parties have obtained prior written authorization from you or have followed SFUSD policies and procedures to access such information.

5) Expiration:
This authorization expires on June 30, 2029.

6) Your Rights:

  • You may refuse to sign this form.
  • You may cancel it at any time by informing our agency in writing. If you cancel your permission allowing us to release information to DCYF and SFUSD, and SFUSD to our agency, it will go into effect immediately unless the information has already been released.
  • You have the right to receive a copy of this form.
(Please select "Yes" or "No")

By signing below, I confirm that I have read and fully understand the above terms and agree to them.

has my permission to participate in any activities at ABADA-CAPOEIRA SAN FRANCISCO
(Parent or Guardian legal name /Name Signature Agreement) Participation is contingent upon student's following ACSF's expectations and exhibiting positive behavior.
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