Summer 2012 and School Year 2012-2013 Student Enrollment Application

Submitted by TerpSys on September 20, 2010 - 12:58pm

INSTRUCTIONS:

You must complete a separate application for EACH student you wish to enroll in FLOC program(s). To submit this form, you must answer all appropriate questions. For required signatures, please type your initials into the box. When you attend your Family Orientation, you will be asked to provide your signature on the application. The application form must be signed by the student’s legal parent / guardian(s). If you are not the student's legal parent/guardian, you may initial online but we will need to collect the parent/guardian signatures at Family Orientation or shortly after.

ENROLLMENT PROCESS

Step 1: Submit a complete application form with all questions answered.

Step 2: Sign up for a Family Orientation and Student Testing Session (done at the same time) by contacting the Recruitment and Outreach Manager Elizabeth Metz at 202-349-3512 or emetz@floc.org.

Step 3: Attend your Family Orientation and Student Testing session. Please bring all required documentation (most recent report card or transcript, supplemental education plans, etc.) with you.

Step 4: Receive notification of your application status.

APPLICATION CHECKLIST

YOU ARE REQUIRED TO SUBMIT THE FOLLOWING DOCUMENTS IN ORDER FOR YOUR STUDENT(S) TO BE CONSIDERED FOR FLOC PARTICIPATION. Please submit your application as soon as possible and bring other documentation with you to your Family Orientation.

Documents Required for All Students:

The FLOC Application Form with ALL questions answered
Most recent report card / transcript
Most recent standardized test scores (DC CAS, etc)

Documents Required for Students Receiving Supplemental Services at School:

Individualized Educational Plan (IEP)
Functional Behavior Assessment
Behavior Intervention Plan
504 Plan

Today's Date (MM/DD/YYYY): *

Student's First Name: *

Student's Last Name: *

2012-2013 Grade: *

Full Name of Person Completing this Application: *

Your Relationship to the Student: *

FLOC PROGRAMS

The following FLOC Programs are available:

The Neighborhood Tutoring Program (NTP), grades 1-12
The Scholars Program, grades 6-12

PLEASE IDENTIFY THE PROGRAM(S) YOU ARE INTERESTED IN ENROLLING YOUR STUDENT IN (check all that apply):

2012 NTP Summer Session Programs (June 25- August 2):

NTP Reading Program: rising 2-6 graders (Monday and Wednesday 6pm - 8pm)

NTP Math Program: rising 2-12 graders (Tuesday and Thursday 6pm - 8pm)

* Please note for summer intensives, students must be able to attend both nights of program. You may apply for a student to be in both programs, but he/ she will only be placed in one.

2012 Scholars Summer Session Programs (June 25- August 2):

Test Preparation Workshops, rising 9-10 graders (Monday 6pm - 8pm)

Test Preparation Workshops, rising 11-12 graders (Wednesday 6pm - 8pm)

Exploring Zoology Workshops, rising 6-8 graders (Monday June 25, July 2, or July 9 5pm - 7pm)

Computer Programming Workshops, rising 6-8 graders (Monday July 9, July 16, or July 23 5pm - 7pm)

2012-2013 NTP School Year Programs (October 2012-May 2013): *

NTP Reading Program: 1-5 Grade (Tuesday 6pm - 8pm)

NTP Reading Program: 6-12 Grade (Wednesday 6pm - 8pm at off-site location)

NTP Math Program: 3-12 Grade (Thursday 6pm - 8pm)

NTP Math Program: 1-12 Grade (Saturday 10am - 12pm)

NTP Reading Program: 1-12 Grade (Saturday 1:30pm - 3:30pm)

*Please note: Students cannot be enrolled in both Saturday NTP programs.

2012-2013 Scholars School Year Programs (October 2012-May 2013): *

Middle School Scholars Program, 6-8 Grade (Monday 6pm - 8pm)

High School Scholars Program, 9-11 Grade (Wednesday 6pm - 8pm)

High School Scholars Program, 12 Grade (Wednesday 6pm - 8pm + an additional day for advising)

* Please note: 12th grade applicants will be contacted by a Program specialist before enrollment.

STUDENT INFORMATION

Student's Current Address: *

City:

State:

Zip Code:

Neighborhood:

Ward #:

Birth Date (MM/DD/YYYY): *

Age: *

Sex: *

Student Cell Phone:

Student Email:

Ethnicity: *

STUDENT EDUCATION INFORMATION

School: *

School City:

School State:

School Type:

Student ID #: *

* Required- please check the report card or call the school if you don't know the #

Is your child eligible for free or reduced lunch?:

Has your student ever been retained a grade or had a prolonged absence from school?:

Yes

If so, when and why?:

Does your student have any of the following plans to receive supplemental services or accommodations at school?

Individualized Educational Plan (IEP): *

Yes

Functional Behavior Assessment: *

Yes

504 Plan: *

Yes

Behavior Intervention Plan: *

Yes

FLOC INVOLVEMENT

Has THIS student ever participated in any FLOC programs before?: *

If yes, indicate the program(s) and years of involvement:

Has THIS student ever been suspended or expelled from a FLOC program for any reason?:

Yes

If yes, please explain the situation::

Does this student have any siblings who are/have participated in FLOC programs?: *

If yes, give the name(s) of the student's siblings and the years of their involvement::

Does this student have any other relatives who are/have participated in FLOC programs?: *

If yes, give the name(s) of the student's relatives and the years of their involvement::

Please provide specific details regarding how you heard about FLOC (Ex. flyer location, specific website, etc.):

PARENT/GUARDIAN 1 INFORMATION

Please check this box if this Parent / Guardian should be FLOC’s primary contact for this student.: *

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to Student:

Primary Language Spoken:

Email:

If other, please specify:

Employer:

Work Phone:

Home Phone:

Cell Phone:

Best Way to Contact:

If this Parent/Guardian has the same address as the student, please check this box and skip to the next section.: *

Address:

City:

State:

Zip Code:

PARENT/GUARDIAN 2 INFORMATION

Please check this box if this Parent / Guardian should be FLOC’s primary contact for this student.: *

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to Student:

Primary Language Spoken:

Email:

If other, please specify:

Employer:

Work Phone:

Home Phone:

Cell Phone:

Best Way to Contact:

If this Parent/Guardian has the same address as the student, please check this box and skip to the next section.: *

Address:

City:

State:

Zip Code:

EMERGENCY CONTACT INFO (Required - Other than parent/guardian)

Full Name: *

Relationship to Student: *

Email:

Primary Language Spoken: *

Employer:

Work Phone:

Home Phone:

Cell Phone:

Best Way to Contact:

STUDENT'S FAMILY BACKGROUND & HOUSEHOLD INFORMATION

This information will be used to process a student's application and for FLOC's statistical reports to organizations that make donations to the FLOC program.

You are required to answer all questions, as your responses will be used to verify your child's eligibility for our program(s). Your application will not be complete and your child will not be considered for enrollment into any FLOC program(s) until all information is received. All of your responses will be kept confidential.

What is the level of education of the student's parents?: *

What is the marital status of the student's primary parent/guardian?: *

What is the annual income of the student's primary household? (Adjusted gross annual income, based on 2011 taxes)*: *

* If you did not file taxes in 2011, please provide the best estimate of your household income including TANF, SDI/ Social Security, retirement, child support, alimony, etc. For Love of Children may require documentation to verify household income.

Do you receive TANF/AFDC?: *

How many adults (over the age of 18 and including yourself) live in the student's primary household?: *

How many children (younger than 18-years-old and including the student/applicant) live in the student's primary household?: *

If other, please specify:

SIGNATURE

I certify that the above information is accurate to the best of my knowledge.
I understand that my student is being considered for admission into For Love of Children program(s), and that submitting this application and attending an orientation does not guarantee my child a place in any FLOC program.
I understand that before my student will be considered for any FLOC program, I must admit all required documentation (application form, report card/ transcript, standardized test scores, and any applicable supplemental education plans).
I understand that if my student is chosen to participate in FLOC programs, he/ she must attend program regularly.

Parent/Guardian Signature (type initials in box):

Date:

MEDICAL HISTORY FORM

ALL ITEMS MUST BE FILLED OUT BY A LEGAL PARENT / GUARDIAN IF THE PARTICIPANT IS UNDER 18 YEARS OLD. You must explain “Yes” answers below.

Has / does the participant:

1. Had any recent injury, illness or infectious disease?: *

2. Have a chronic or recurring illness/condition?: *

3. Take medication (prescribed or over the counter)?: *

4. Ever been hospitalized?: *

5. Ever had surgery?: *

6. Have any emergency allergic reactions (bee stings, food, etc.)?: *

7. Have frequent headaches?: *

8. Ever had a head injury?: *

9. Ever been knocked unconscious?: *

10. Ever had frequent ear infections?: *

11. Ever passed out during or after exercise?: *

12. Ever had seizures?: *

13. Ever had chest pain during or after exercise?: *

14. Ever had high blood pressure?: *

15. Ever been diagnosed with a heart murmur or any other heart condition?: *

16. Ever had back problems?: *

17. Ever had problems with joints (knees, ankles, etc.)?: *

18. Have any skin problems (itching, rash, acne, etc.)?: *

19. Have diabetes?: *

20. Have asthma?: *

21. Had mononucleosis in the past 12 months?: *

22. Had problems with diarrhea/constipation?: *

23. If female, have an abnormal menstrual history?: *

24. Have a history of bedwetting?: *

25. Have problems with sleepwalking?: *

Please explain any "Yes" answers, noting the question number(s):

If your student has ANY food allergies or dietary restrictions, please list them here:

If your student has any other allergies, please list them here:

Please list all prescription AND over-the-counter medications that you authorize this student to have and self-administer at FLOC:

Additional medical issues/activity restrictions that you would like to share:

SIGNATURE REQUIRED

I certify that the medical information provided above is accurate to the best of my knowledge. I understand that FLOC will not allow my child to take medications not listed on this form without direct consent from a parent / guardian. I understand that I am required to give medical consent in order for my child to participate in any FLOC program(s).

Parent/Guardian Signature (type initials in box):: *

RELEASE FORM

This form is required with all appropriate signatures. You MUST be the student’s legal parent or guardian to complete this form.

Name of Parent/Guardian Completing the Release Form: *

Medical Authorization

I grant permission for a representative of For Love of Children to have my child treated at an appropriate facility in the case of an emergency while my child is in attendance at a For Love of Children program. I understand that representatives of For Love of Children are not medical professionals and will only seek medical assistance from a licensed medical facility in case of emergency when I cannot be reached. I waive my right to prosecute any representative from the program who proceeds as above.

Reports and Standardized Test Results

I grant permission for a representative of For Love of Children to request and receive copies of my child’s report cards, transcript, standardized test results, and supplemental education plans (IEP, behavioral plans, etc.) from my child’s school.

Other Service Providers

I grant permission for a representative of For Love of Children to communicate with other agencies/service providers who are providing assistance to my child, including school counselors, teachers, social workers/case managers, or other non-profit agencies. I understand that FLOC will be communicating with these providers in order to better coordinate services to help my child, and that information about my child will not be shared with anyone outside of the providers, FLOC staff, me, and/or other legal parents or guardians.

Media, Photography, and Video

I understand and give permission to For Love of Children and approved partners to use information about my student's involvement and progress in program as well as photos or video of my child for use as FLOC deems appropriate for publicity and fundraising purposes. I understand that FLOC will keep my child’s name confidential unless I give permission for use of my child’s first name for publicity purposes (or with photos or video) by answering “Yes” to the following question.

Does FLOC have permission to include your child's first name with stories, pictures, or videos?: *

Yes

Please note: For Love of Children will contact you directly for permission if we ever wish to use your child's full name (first and last) for publicity or fundraising purposes.

Dismissal from Program

I grant permission for my child to be dismissed from FLOC program(s) by (check all that apply): *

Walking or taking public transporation home

Attending an After Care Program at his / her school (school sites only)

Being picked up by Parent / Guardian

Being picked up by another authorized person (names must be listed on next question)

In addition to me, the following people have permission to pick my child up from FLOC program (please list full names and relationships)::

Permission

I have read and understand all of the above, and want my student to be considered for participation in FLOC.

Parent/Guardian Signature (type initials in box):: *

Date (MM/DD/YYYY): *

The following is REQUIRED for applicants of the Scholars Program (6-12 grade workshops).

Off Site Visit

I give permission to FLOC to escort my child off-site for occasional workshop excursions (transportation may include use of FLOC van, as well as Metro trans and buses). I understand that FLOC will notify me in advance if field trips occur at a time other than the regularly scheduled workshop hours.

Direct Communication with 6th-12th grade students

I give permission to the FLOC staff to communicate with my child directly through e-mail, cellular phone, and social media websites.

Parent/Guardian Signature (type initials in box):: *

For Love of Children Teach. Empower. Transform.

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Summer 2012 and School Year 2012-2013 Student Enrollment Application