IN REAL LIFE Registration Spring Session April 6 – May 29th, 2015 Student Name: ____________________________________________ Grade: 6th □ 7th □ 8th □ Homeroom Teacher: _______________________________________ PROGRAM CHOICES: Please, write your first and second program choices beneath the appropriate day of the week. Monday Tuesday Wednesday Thursday IRL Study Hall IRL Study Hall IRL Study Hall IRL Study Hall Friday First Choice Second Choice Please circle PROGRAM SCHEDULE: Programs often fill quickly. Please return completed Forms in a timely manner. Monday Tuesday CTC closed ETT/ UNCA closed Triple G - Mixed Martial Arts Girl Scouts FEAST Wednesday Theater Arts – Grant Center or AMS Crossfit Pisgah Fired Up Plato's Cafe Bridge Project EMPOWER Circus Arts– Toy Boat Ultimate Frisbee Math Lab The Hunger Games ELA Dungeons and Dragons *Slacklibrium* Thursday Explore + Experiment with Indie Craft Jewelry Iron Girls Lyrics to Life Telescoping AOB Poetry ELA *Slacklibrium* *Case Management* Friday Forensic Science Kickball Future Leaders of America NO STUDY HALL *Case Management* KEY: BOLD: Off-site Programs *Asterisk*: Multiple Day Programs Separate registration forms are required for Project Empower and LEAF programs. Applications are available in the IRL Office. IRL Programs are available to ALL Asheville City Schools Middle School Students. ---- NO student will be turned away based on financial need! --Full & Partial Scholarships available to those who need it. *IRL Spring 2015 Registration begins March 16th* PLEASE COMPLETE ALL OF THE NECESSARY FORMS IN THE REGISTRATION PACKET & RETURN THEM TO THE IRL OFFICE, AMS MAIN OFFICE OR YOUR TEACHER. IRL ADD/DROP Schedule: March 16th – April 24th 2015. No refunds after programs begin. No refunds will be given if your child is asked to leave IRL programs. [email protected] ● (828) 350-6270 ● www.acsf.org IRL Staff Only Date Received: __________ Date Processed: __________ Staff Initials: _________ Student Name: _________________________________________ DOB: ____/____/____ Homeroom Teacher: ____________________________________ Grade: 6th □ 7th □ 8th □ Age: ________ THIS PAGE DOES NOT NEED TO BE COMPLETED IF YOU ARE RETURNING TO IRL 2014-2015. FAMILY INFORMATION Parent/Legal Guardian Name: _____________________________________ Relationship: ________________________________ Street Address: _______________________________________ City: _______________ State: ________ Zip: __________________ Home Phone: ________________________ Cell Phone: ________________________ Work Phone: ________________________ What is the best phone number to reach you? Home □ Cell □ Work □ Email: ____________________________________________ Parent/Guardian (2) Name: _______________________________________ Relationship: ________________________________ Street Address: _______________________________________ City: _______________ State: ________ Zip: __________________ Home Phone: ________________________ Cell Phone: ________________________ Work Phone: ________________________ What is the best phone number to reach you? Home □ Cell □ Work □ Email: ____________________________________________ EMERGENCY CONTACT INFORMATION Name: _______________________________ Relationship: ________________ Phone: ____________________________________ Name: _______________________________ Relationship: ________________ Phone: ____________________________________ MEDICAL INFORMATION Primary Doctor: _________________________________ Phone: ________________________ Fax: ________________________ Primary Dentist: _________________________________ Phone: ________________________ Fax: ________________________ Insurance Carrier: _______________________________________ Policy No: _________________________ ALLERGIES: Yes □ None □ If yes, Allergic to ______________________________ Reaction: ________________________ Meds (if any) ___________________ Allergic to ______________________________ Reaction: ________________________ Meds (if any) ___________________ MEDICATION: Is your child taking medication regularly? Yes □ None □ If yes, please specify for what & dosage: ___________________________________________________________________________ ASTHMA: Does your child have asthma? Yes □ No □ If yes, does your child have an inhaler? Yes □ No □ If yes, please describe _________________________________________________________________________________________ Are there any other medical concerns that we need to know about? Yes □ No □ If yes, please describe ________________________ __________________________________________________________________________________________________________ Are there any other special considerations that we need to know about your child? Yes □ No □ If yes, please describe _____________ __________________________________________________________________________________________________________ Demographic information obtained is used to help ensure that IRL is able to serve all students equitably. These questions are optional. Gender: _____________ Household Status: Single Parent □ Both Parents □ Other Relative □ Other Adult □ Free & Reduced Lunch: Yes □ No □ Racial/Ethnic Background: Asian □ African American □ African Non-American □ American Indian or Alaskan Native □ Caucasian □ Hispanic/Latino □ Native Hawaiian or Pacific Islander □ Multi-ethnic □ Other □ _____________________ We value your input & involvement in IRL. IRL PARENT Information. Please, mark what IRL Sessions your child has participated in: We participated in IRL last year. □ [email protected] ● (828) 350-6270 ● www.acsf.org We are new to IRL □ I am interested in learning more about volunteer opportunities with IRL. Yes □ No □ I would like to sign up to receive e-mail updates about IRL/ACSF. Yes □ No □ If yes, email:_______________________ IRL PROGRAM FEES & SCHOLARSHIPS *Your investment & commitment to our programs is important. We do offer full & partial scholarships to all students/families in need and won’t turn anyone away. We ask that all families contribute something if possible…even $1.00 per program choice. Thank you for your support. *IRL STAFF* □ I can pay the full amount of $56.00 per IRL program that my child is enrolled. □ I can pay the full amount AND I can sponsor another child's participation in IRL for the amount of $________________. □ I cannot pay the full amount and will need a partial scholarship. □ I can pay $40.00 per program that my child is enrolled. □ I can pay $20.00 per program that my child is enrolled. □ I can pay $_____ per program that my child is enrolled. *We Accept Cash & Checks* Make checks payable to Asheville City Schools Foundation TOTAL AMOUNT DUE: ____________. THANK YOU FOR YOUR SUPPORT! IRL Cancellation Policies & Refunds: Please Note: Spring Sports schedules overlap with IRL program dates. - You may cancel or switch programs during ADD/DROP: December 15th – January 30th. - No refunds will be given if your child is removed from a particular program due to behavioral issues or consistently late pick-ups at the end of the day. - All other inquiries regarding cancellations or refunds will be handled on a case by case basis. Contact Erin Cotter, IRL Director. TRANSPORTATION....Getting Home. Yes □ No □ Yes □ No □ I am able to PICK-UP my child at the end of the day from Asheville Middle School. Parent pick-up is 5-5:15after programs OR 5:45pm after Study Hall (M-TH). All students need to be picked up BY 5:45pm (M-Th) 5:15 on Fridays. PICK UP is at Asheville Middle School at the front door. I want to make arrangements for my child to be taken home on the AFTER-SCHOOL BUS. This student will attend Study Hall (M-Th). Yes □ No □ The after-school bus leaves AMS at roughly 5:45pm daily and makes neighborhood stops. Please, contact Angel in the IRL Office, 828-350-6270 to confirm your bus stop and child’s seat on the bus. I grant my child permission to WALK HOME from Asheville Middle School following IRL programs. If you are able to pick-up your child at the end of the day, please complete the following information to ensure the safety of your child. The names of the people listed below will be the only ones allowed to pick your child up at the end of IRL programming. MY CHILD MAY BE PICKED UP BY: Name: ________________________________ Relationship: _______________ Phone: ____________________ Name: ______________________________ __ Relationship: _______________ Phone: ____________________ MY CHILD MAY NOT BE PICKED UP BY: Name: ______________________________ __ Relationship: _______________ In Real Life - Permission (Parent/Guardian) [email protected] ● (828) 350-6270 ● www.acsf.org Name: ________________________________ Relationship: _______________ We would like to ask your permission for the following: Your answers to these questions will not impact your child’s participation in the In Real Life programs. If you answer “no” to any of the questions, your child may still participate fully in the program. Please be sure to check YES or NO for each question. 1. The Asheville City Schools Foundation, In Real Life and the Service Providers will use photos in publicity and marketing materials to promote their programs. I hereby grant permission for my child's image to be used, voluntarily and without compensation, by the Asheville City Schools Foundation & participating service providers, understanding that the same is intended for publication by print media, newspaper, television, video, and ACSF promotional materials, including the ACSF website and e-newsletter. Images will only be used to promote the Asheville City Schools Foundation and the Service Providers participating in the In Real Life Network of after-school programs. Yes, I give my permission No, I do not give my permission 2. In order to ensure safety and program quality, the Asheville City Schools Foundation, In Real Life and participating Service Providers may conduct surveys from time to time of me, my child and/or my child’s family, and use the information acquired therein to provide feedback, suggestions, and/or evaluation of the In Real Life programs and programming and other legitimate purposes of the Asheville City Schools Foundation and the In Real Life program providers. Do we have permission to conduct surveys with you and/or your child for these purposes? Yes, I give my permission No, I do not give my permission 3. In order to support the academic success of your child & to track the impact of IRL on academic achievement and readiness, IRL requests permission to access your child’s student educational records including: grades , benchmark, EOG/EOC scores, school attendance & discipline referrals, IEP, etc. Yes, I give my permission No, I do not give my permission Release (Please read carefully and sign where indicated) I, the undersigned, hereby understand, acknowledge, and agree that: I have read and understand the information provided to me explaining the In Real Life program. ● I hereby give my permission for my child to participate in the In Real Life program, at the locations specified for any particular Service Provider program and agree that my child will obey all program rules and guidelines. I understand that participation by my child in the In Real Life Program may involve certain risks. I understand that by allowing my child to participate in the In Real Life programs, I am assuming all of these risks, including but not limited to, any physical risks or risk of injury that may be associated with the nature of any In Real Life Program. All individuals delivering In Real Life programs are employees of or volunteers with the individual Service Providers operating these programs and these providers are responsible for the operation of their program and the supervision of their staff. The Asheville City Schools Foundation, Asheville City Schools, and the In Real Life program take no responsibility for any occurrence relating to or arising out of the programs operated by individual Service Providers. I grant permission for my child to ride on activity buses between program sites, and, if selected, use the transportation home that is provided by In Real Life, but realize that my family is ultimately responsible for arranging and providing transportation home, as necessary. I hereby give my permission for a representative of the Asheville City Schools Foundation, Asheville City Schools, or individual Service Providers to obtain emergency medical assistance and authorize medical treatment and any medical procedure that is considered to be in the best interest of my child whenever I am not readily available and to grant such authority and permission directly to the doctor or hospital involved. I hereby release, waive and indemnify Asheville City Schools, the Asheville City Schools Foundation, and the individual Service Providers, and their respective officers, directors, trustees, agents, servants, and employees from any and all claims, liabilities and damages arising during or from my child's participation in any In Real Life sponsored activity or program, including personal injury, wrongful death or property damage. Further I agree that I will not seek to hold Asheville City Schools, the Asheville City Schools Foundation, or its Service Providers, as listed in the In Real Life catalog, responsible for any losses or damages which I or my child may incur in connection therewith, including any mistakes, negligence, omissions, or acts whatsoever of any party in connection with the In Real Life Program. Parent Signature: _____________________________________________________ Date: _______________________________________________ Parent Name (Please Print): __________________________________________ Developmental Assets Survey - PASSIVE CONSENT - Please READ! IRL will be conducting a very important study on the needs, attitudes and behaviors or our youth! The survey is titled the Search Institute Developmental Assets Profile (DAP). It will provide our program and community with a wide range of information, such as how youth spend their time, their perceptions of school and community life, and their participation in a wide range of risky behaviors. Most important, the survey will tell us the extent to which our youth are experiencing Developmental Assets. Developmental Assets are the "building blocks" of positive relationships, opportunities, skills and values that young people need to grow into healthy, caring, and responsible adults. The DAP Profile and a FACT SHEET for parents is available upon request at the IRL Office. □ Please withdraw my child from participation in the Developmental Assets Profile (DAP) survey. ______________________ Initials & Date [email protected] ● (828) 350-6270 ● www.acsf.org
© Copyright 2024