BCHS - Barren Beyond the Bell Registration

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Please complete registration form for the 2020-2021 school year. Registration MUST be on file in order to participate in any before or after school activity.

Email *

Student Name: First, Middle Initial and Last *

Address: Street, City, State and Zip Code *

Grade - Choose 1 *

Freshman (9)

Sophomore (10)

Junior (11)

Senior (12)

Student Date of Birth: *

Gender *

Female

Male

Prefer not to say

Other:

Lunch Status - Please choose 1 *

Free

Reduced

Full pay

Unknown

Ethnicity - Please choose 1 *

American Indian / Alaskan Native

Asian

Black (not of Hispanic origin)

Hispanic

Native Hawaiian or other Pacific Islander

Other/Unknown

Two or more races

White (not of Hispanic origin)

Other:

Primary Language - Choose 1 *

English

Spanish

Other:

Student Lives With (Please Choose 1): *

Both Parents

Foster Care

Grandparents

Guardian

Joint Custody

Single Parent Father

Single Parent Mother

Other:

Activity student is interested in (please check all that apply): *

Homework Help/Tutoring

Extended Library Hours (Research/Computers/Printer Access)

Archery

Drama

Other:

Required

Are you interested in participating in morning (before school) hours or afternoon (after school) hours? *

Morning

Afternoon

Both

Will your child be attending an "extended library session" in the library beginning at 6:45 AM? *

Yes

Other:

Will your child attend an afternoon session? *

Yes

If your child will attend an afternoon session, please choose a pick up time that best suits your needs. *

4:00

5:00

My child is not attending an afternoon session

Are you interested in virtual programming for your child/ren? i.e tutoring, camps, etc. *

Yes

Other:

Special needs (i.e. medications, allergies, diet, etc): *

Parent/ Guardian 1 Name: (First, Middle Initial and Last): *

Parent/Guardian 1 Relationship: *

mother

father

Other:

Parent/Guardian 1 - Best Phone Number for Contact *

Parent/Guardian 2 Name (First, Middle Initial, Last):

Parent/Guardian 2 Relationship:

Mother

Father

Other:

Clear selection

Parent/Guardian 2 - Best phone number for contact:

ADDITIONAL CONTACTS: List additional contacts for student. Please include Name (First and Last), Address, and a good phone number for each contact. Also, please indicate if these individuals are authorized to pick up the student and/or will serve as an emergency contact. If no adults are listed below, ONLY THE PARENT(S)/GUARDIAN(S) WILL be able to pick up the student(s). ***There must be a minimum of 2 adult contacts for student*** *

Are there any legal restrictions in effect preventing certain individuals from seeing and/or picking up student? If yes, please indicate the person/s name below. If no, please answer no and continue on. ***Please note that our school will need legal documents in order to enforce the no contact*** *

Please read each of the following statements and check the box next to each to consent for 21st CCLC participation: *

I give permission for the participant(s) listed to take part in the 21st Century Community Learning Centers activities, which may include off-site events, academic assistance, continuing education, and recreational programs.

If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred.

I agree that if a health condition exists now or in the future which would impact the participation of those listed on front, I will notify the 21st Century Community Learning Center staff.

I give my consent to the School District and the 21st Century Community Learning Centers programs to take the participants photograph during program activities, to be used for education and public relations purposes.

I further give my consent to the School District and the 21st Century Community Learning Centers (CCLC) to share the participants student records with each other for purposes of providing educational support and assistance.

In addition, I understand that the 21st Century Community Learning Center will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement. The student data will also be used to fulfill the State and Federal annual progress reporting requirements to obtain continued funding for the program.

I give permission for my child's image, voice, or written comments to be included in evaluations, pictures, newsletters and marketing pieces associated with the program. 21st CCLC may use these indefinitely, without limitations or obligation, for the purpose of promoting 21st CCLC programs.

I acknowledge on behalf of myself and my dependents that I assume the risk for any injuries or illnesses, which may result from activities. I hereby release and discharge the 21st CCLC, it's agents, servants, and employees from any and all claims for injury, illness, loss or damage, which my child may suffer as a result in his/her participation in the after school program.

I understand that the 21st CCLC is not responsible for personal property lost or stolen while participating in the program. My child is responsible is responsible for his or her belongings. There is NO lost and found.

Finally, I understand that the 21st CCLC program is not responsible for anything that occurs as the result of false information given to us by parent/guardian.ion 10

Required

By typing your name below you are certifying that you have read and understand the above agreement and are authorized to sign for the mentioned student to participate in the BCHS Barren Beyond the Bell 21st CCLC after-school program. *

A copy of your responses will be emailed to the address you provided.

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