IRL Registration FALL 2015 Session: September 9th- December 11, 2015 Student Name: ____________________________________________
Grade: 6th □ 7th □ 8th □
Homeroom Teacher: _______________________________________
PROGRAM CHOICES: Please, write your 1st and 2nd 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
Wednesday
Thursday
Friday
Paws On!
CrossFit Kids
Bug Camp @ UNCA
Printmaking & Mixed Media
Iron Girls
Latin Dancing
Roots + Wings
ELA tutoring Mrs. Doherty
Speech & Debate
Getting Back to the Basics
FEAST
*Slacklibrium*
ELA tutoring Mrs. Kalen
*Slacklibrium*
Future Leaders of Asheville
Chess & Strategic Games
Sportsfit
Math tutoring Mrs. Keupp
*Heart & Sole*
*Heart & Sole*
Youth Bridge
Math tutoring Mr. Mikulski
Dungeons & Dragons
West African Drumming
Media Dissection
*Back On Track*
Bike Club
Project EMPOWER
Darkroom Photography 101
*Back On Track*
KEY: BOLD: travels off-site *Asterisk* multiple days Italicized: Additional forms needed (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 Fall 2015 Registration begins August 19th* 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: September 9th-September 31st No refunds after programs begin. No refunds will be given if your child is asked to leave IRL programs. irl@acsf.org ● (828) 350-6270 ● www.acsf.org
Student Name: _________________________________________
DOB: ____/____/____
Homeroom Teacher: ____________________________________
Grade: 6th □ 7th □ 8th □
Age: ________
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: ____________________________________________
DEMOGRAPHIC INFORMATION Demographic information obtained is used to help ensure that IRL is able to serve all students equitably. All information is held in highest CONFIDENTIALITY and will not be shared. These questions are optional.
Gender: _____________ Household Size: □Single Parent □ Both Parents □ 1 child □ 2 Children □ 3 children □4+ Children Annual Household Income: □>$10K/year □$10K-25K/year □$25K-35K/ year □over $35K/ year 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 □ _____________________
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 _____________ __________________________________________________________________________________________________________
irl@acsf.org ● (828) 350-6270 ● www.acsf.org
We value your input & involvement in IRL. 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. $1.00 per program choice is requested. Thank you for your support. *IRL STAFF* □ I can pay the full amount of $84.00 (for 12 weeks of programming) per IRL program that my child is enrolled. *Please contact the IRL office if monthly payments are requested.* □ 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 $50.00 per program that my child is enrolled. □ I can pay $25.00 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: Sports schedules overlap with IRL program dates. - You may cancel or switch programs during ADD/DROP: September 9th – September 31st. - 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) 5:30 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 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: ____________________
In Real Life - Permission (Parent/Guardian) MY CHILD MAY NOT BE PICKED UP BY: Name: ______________________________ __
Relationship: _______________
Name: ________________________________
Relationship: _______________
irl@acsf.org ● (828) 350-6270 ● www.acsf.org
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 agree to allow the City Of Ashville to view student files as a part of the City Development Block Grant funding. 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): __________________________________________ The 21st Century Community Learning Centers Program Annual Performance Report - PASSIVE CONSENT - Please READ! IRL will be conducting a very important study on the needs, attitudes and behaviors of our students as they attend 30+ days of IRL. We will be using the 21st Century Community Learning Centers Program Annual Performance Report (APR) with information reported by teachers. It will provide our program and community with a wide range of information, such as how students perform in the classroom, their school preparedness and classroom engagement. Most important, the survey will tell us the extent to which our youth are experiencing pro-academic growth based on afterschool access and participation. IRL provides the "building blocks" of positive relationships, opportunities; skills and values that young people need to grow into healthy, caring, and responsible adults. □ Please withdraw my child from participation in the 21st Century Community Learning Centers Program APR survey. ________________ Initials & Date
irl@acsf.org ● (828) 350-6270 ● www.acsf.org