*Expanded Learning Programs can change based on school reopening guidelines*

If you are interested in your student attending the William Land Expanded Learning Program (Lion's Den), please complete this interest form. This form is for 1st grade through 6th grade, if you have an incoming kindergarten student, please visit https://forms.gle/SXpBn4KyyruRbC2Y8 to fill out an Incoming Kindergarten Expanded Learning Interest Form.
 
These student groups will be given priority: students in foster care, students experiencing homelessness, English Language Learners, students receiving Special Ed services and students experiencing disengagement (defined as chronically absent, multiple missing assignments, and teacher recommendation). We are currently accepting applications for our WAITLIST, you will be contacted as space becomes available.

Students will be provided supper, academic supports, tutoring, physical activities, and enrichment activities provided by supplemental providers.
 
Please complete one form per student. Complete application and click "Submit" at bottom of page.

Please complete one form per student.

Please indicate how your child will get home from his/her After School Program:

Request for Permission: We are asking your permission for your child to take part in a district evaluation of the after school program offered at your child’s school site. As part of the study, we will be asking your child, your child’s teacher, and school administrators to share information that will tell us about your child’s experiences in the program. This will help us measure changes in your child’s attitude; behavior and/or academic achievement that may have resulted from his/her participation.
Your consent and your child’s participation in the study are completely voluntary. Your child may decide not to participate, to only answer specific questions, or leave the study at any time without penalty.

Purpose of the Study: The information we will be collecting for the study is a requirement of the California Department of Education (CDE), this government agency provides funding for the program. The information will help us learn whether or not the program has been successful. Your child’s participation will help us to continue to provide quality after school programs in the future.

Confidentiality: All of the information used for the study will be completely confidential and will not be seen by anyone except those people working on the study. Your child will be assigned a code number so that responses to any questions we ask cannot be linked back to your child. Names will not be used.

I, the undersigned, am parent and/or legal guardian of the student noted on this document, and hereby fully release and discharge the Sacramento City Unified School District, Sacramento Chinese Community Service Center, Inc., Target Excellence, New Hope Community Development Corporation, the Boys & Girls Club of Sacramento, Club Z!, Sacramento START, Think Together, Inc., City of Sacramento, and other contracted service providers, their officers, employees, agents, servants, and volunteers from any and all liability arising in connection with the above-described independent activities and all liabilities associated with any and all claims related to such activity that may be filed on behalf or for the above named minor. For the purpose of this release, “liability” mans all claims, demands, losses, causes of actions, suits or judgments of any and every kind that arise as a result of the above described activity and resulting from any cause other than the district’s, city’s and/or agency’s negligence.

I, the undersigned, am the parent and/or legal guardian of the minor child listed on the first page of this form.  I hereby fully release, waive forever discharge, hold harmless and agree not to sue the Sacramento City Unified School District (“District”) and its Board of Education, the City of Sacramento, Sacramento Chinese Community Service Center, Inc., Target Excellence, New Hope Community Development Corporation, the Boys & Girls Club of Sacramento, Roberts Family Development Center, Rose Family Creative Empowerment Center, Center for fathers and families and any other contracted service providers of the District’s ASES or ASSETS After School Programs (“Programs”) (jointly referred to as “the Parties”), as well as the Parties’ officers, employees, agents, servants, and volunteers from any and all liability arising out of or in connection with my child’s participation in the Programs, and all liabilities associated with any and all claims related to such participation that may be filed on behalf or for my child.  For the purpose of this release and waiver, “liability” means all claims, demands, losses, causes of action, suits or judgments of any and every kind that arise as a result of my child’s participation in the Programs and that result from any cause other than the Parties’ gross negligence.

By signing below I give permission for my child to participate in the Programs.  I also give my consent to any medical treatment deemed necessary by medical personnel for the physical well-being of my child.  I assume full responsibility for my child’s behavior and agree to pay for all damages to property or person caused by him/her.  I understand that I will be notified if my child’s behavior interferes with the Programs, and that further disciplinary problems may result in his/her expulsion from the Programs.  This release and waiver shall remain in effect while my child is participating in the Programs.  I understand that I may revoke my consent in writing.  However, if I do so my child will no longer be permitted to participate in the Programs.

I understand that this release and waiver is intended to be as broad and inclusive as permitted by the laws of the State of California, and agree that if any portion is held invalid, the remainder of this release and waiver will continue in full force and effect.

I consent to the District releasing information regarding my child that is protected from disclosure by the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) and/or the Health Insurance Portability and Accountability Act of 1996 and its accompanying regulations (hereinafter collectively referred to as “HIPAA”) to the City, SCCSC, Target Excellence, the Park District and any other contracted service providers of the Programs.  I understand that the District shall only release such information as necessary for operation of the Programs.

My signature below additionally verifies that I understand that except as otherwise approved, my child is expected to attend the Programs from when he/she is dismissed from school until 6:00 pm, for the full program session.  I also understand that student attendance will be recorded in each class and that I will be required to verify my child’s absences.
I acknowledge that I have had sufficient time to read this entire form.   I have carefully read and understand all of it and I agree to be bound by its terms.