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