Model Building / Titulo del Club/Actividad

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Model Building / Titulo del Club/Actividad

General Description of Club/Activity: / Descripcion General del Club/Actividad: Students in Model Club will build scale models of vehicles from a kit.).

$25.00 Kit Fee

This class is for students 4th - 6th grade

Limit: 10 Students

Day(s) of the Week: / Day(s) of the week: Tuesdays

Dates: / Dates: 07/05/2014 - 05/21/2024

Time: 3:15 am - 4:15 pm / Time: 3:15 am - 4:15 pm

Staff Sponsor(s): / Staff Sponsor(s) Mr Hester

Drop Off Location: Main Office Entrance -Pecos Hug n Go lane / Student Drop Off Location: Main Office Entrance - Hug n Go lane in Pecos

Club/Activity Location (room number): / Club/Activity Location (room number):

*Students who arrive more than 10 minutes late for any Club or Activity may be removed from the activity after the second occurrence. Please be prompt when dropping off your students and be respectful of the sponsor's time. / Students who are more than 10 minutes late for any club or activity may be removed from the activity after the second occurrence. Please arrive on time when dropping off your students and be respectful of the sponsor's time.

Email *

Record my email address with my response

Student First Name / Nombre del Estudiante
*

Student Last Name / Apellido del Estudiante
*

Student Grade / Grado del Estudiante
*

Primary Parent/Guardian Name

First and Last name of primary contact parent/guardian/

Nombre del Padre/Guardian Principal

Nombre y Apellido del Contacto Principal (Padre/Guardian)

Primary contact email

Email del Contacto Principal

Phone Number

What is the best number for the primary contact to be reached during this time?

Numero Telefonico

Cual es el mejor numero para contactar al contacto principal durante este tiempo?

Parent/Guardian Name 2 (optional)

First and Last name of secondary contact parent/guardian

Nombre del Padre/Guardian #2 (Opcional)

Nombre y Apellido del segundo Contacto (Padre/Guardian)

Email (optional)

Secondary contact email

Email (Opcional)

Email del Segundo Contacto

Phone Number (optional)

What is the best number for the secondary contact to be reached during this time?

Numero Telefonico (Opcional)

Cual es el mejor numero para contactar al contacto principal durante este tiempo?

How will your child arrive at STEM Launch? / Como llegara su estudiante a STEM Launch?
*

Car / Carro

Base

Walk/Bike/Skateboard/Scooter / Caminando/En Bicicleta/ En Patineta / En Patin

Other:

Required

Please list any allergies, medical conditions, and dietary restrictions that may impact your child while participating in this club/activity. / Favor del enlistar cualquier alergia, condicion medica, y restriccion dietetica que puede impactar a su estudiante durante su participacion en este club/actividad *

Agreement: Consent for Emergency Medical Care and Sharing of Information/Acuerdos: Consentimiento para la atencion medica de emergencia e intercambio de informacion

By checking this box, I, a parent or guardian of the above named student herein authorizes all adult sponsors, or any responsible adult person bearing this authorization into whose care the above mentioned minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgial diagnosis or treatment and hospital care. Such care is to be rendered to said minor under the general or special supervision and upon the advice of a physician, dentist, and/or surgeon licensed to practice in the State of Colorad and to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care. In addition, I authorize all Beyond the Bell program, school, and district staff to exchange relevant information about my student. It is understood that this authorization is given the After School Program for all program-sponsored activities. Every effort will be taken to locate a parent/guardian before any action is taken. All medical expenses will be accepted by the parent/guardian. The After School Program is absolved of any or all liability for accidents or injuries received during any or all program-sponsored activities./Yo, un padre o tutor del estudiante nombrado arriba en este documento autoriza a patrocinadores todo el adulto, o cualquier persona adulta responsable teniendo esta autorizacion por escrito, en cuyo cuidado lo anterior mencionado menor ha sido encomendada, para su consentimiento para cualquier examen de rayos x, anestesia, cuidado medico, quirurgico de diagnostico o tratamiento y hospital. Este tipo de atencion debe prestarse a dicho menor bajo la supervision general o especial y con el asesoramiento de un medico, dentista o cirujano con licencia para practicar en el estado de Colorado y dar su consentimiento para cualquier examen de rayos x, anestesico, dental o quirurgico de diagnostico o tratamiento y a atencion hospitalaria. Ademas, autorizo a todo program de campamento, escuela y personal del distrito para intercambiar informacion relevante sobre mi estudiante. Se entiende que esta autorizacion se da el programa de campamento para todos las actividades patrocinadas por el programa. Se tomaran todos los esfuerzos para localizar a un padre o tutor antes de tomar cualquier accion. Todos los gastos medicos seran aceptados por los padres/tutores. El programa es absuelto de cualquier responsabilidad por accidentes o lesiones recibidas durante actividades patrocinadas por el programa de cualquier o todas.

I need to be contacted before any medical decisions are made (not recommended in case of emergency)

Required

Agreement: Adams 12 Five Star Schools Adult and Student Code of Conduct/Acuerdos: Adams 12 Escuelas de Cinco Estrellas Arreglo Del Codigo De Conducta Para Adultos Y Estudiantes

Every participant in Beyond the Bell programming, including adult personnel and parents, is a potential role model for our students and community. As role models, we are all expected to portray citizenship, kindness/respect for all, positive communication, problem solving behaviors, and appropriate regard of school property. / Cada persona que entra en programa "Beyond the Bell" incluyendo el personal del "BtB" es sujeto de ser modelo de los estudiantes presentes. Como modelos se espera que TODOS demuentren buena ciudadania cultural, bondad/respeto de todos, comunicacion positiva, la resolucion de comportamientos, y la consideracion adecuada de la propiedad escolar.

Per state law, smoking, drug, and/or alcohol use are never permitted. If suspected abuse occurs, the person(s) involved will be subject to removal from district grounds. / Por ley estatal, el tabaco, las drogas y/o el alcohol no son permitidos en propiedad escolar. En caso de cualquier sospecha, la persona (s) involucrada estara sujeta a la remocion de la propiedad.

All district and Superintendent policies will be adhered to and apply to Beyond the Bell. / Todas las Politicas del Distrito y del Superintendente se adhieren y seran aplicadas al programa de "STEM Beyond the Bell."

While every effort will be made to resolve a conflict, we reserve the right to immediately terminate care should a parent/guardian or custodial dispute affect the program, personnel, or students in a threatening manner. Please refer to the Discipline Procedures and policies within district and school handbooks. / Aunque se hara todo lo posible para resolver un conflicto, reservamos el derecho de suspender cuidado inmediatamente, si el conflicto de un padre/guardian afecta el programa, a un personal o los estudiantes de manera amenazante. Por favor, refierase al manual escolar para ver los Procedimientos Disciplinarios y politicas dentro del distrito.ption 4

I understand and agree to adhere to the "Code of Conduct Agreement"/ Entiendo y estoy de acuerdo en cumplir con el "Codigo de Conducta"

Agreement: Unexpected Closures or Emergency Situations/Acuerdos: Tardanzas, Cerradas inesperadas o Situaciones de Emergencia

If the Adams 12 Five Star School district determines that should school close early or be canceled, all Beyond the Bell activities will also be canceled. In the event that the weather may pose a hazard to students or faculty, the administration at STEM Launch may choose to cancel Beyond the Bell activities, even if school was not cancelled. / Si el distrito escolar Adams 12 determina que la escuela cierre temprano o sea cancelada, toda actividad de Beyond the Bell tambien se cancelaran. En el caso de que el clima puede representar un peligro para los estudiantes o los profesores, la administracion en STEM Launch puede optar por cancelar las actividades de Beyond the Bell, aunque la escuela no sea cancelada.

If programming is cancelled due to inclement weather, we will make an announcement to students at the end of the school day. Such information will also be posted on the STEM Launch website. In the event of a cancellation, students will be allowed to call home to make transportation arrangements. / Si la programacion es cancelada debido al clima, haremos un anuncio al final de la jornada escolar. Dicha informacion tambien sera publicada en el sitio web de STEM Launch. En caso de una cancelacion, los estudiantes se les permitran llamar a casa para hacer los arreglos de transporte.

By typing your first and last name below you are giving permission for your child to participate in this club/activity and acknowledge that your child may be removed from the club/activity if they arrive late 2 or more times. / Al momento de escribir su nombre y apellido abajo usted esta dando permiso para que su estudiante participe en este club/actividad y da consentimiento de que su estudiante puede ser eliminado de este club/actividad si llegan tarde 2 o mas veces.

A copy of your responses will be emailed to .

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