Student Information

First Name

Last Name

School Student Attends

Date of Birth

Gender

Race

Primary Language

Eligible for Free/Reduced Lunch?

YesNo

Address

Address 2

City

State

Zip Code

Add 2nd Student?

2nd Student Information

First Name

Last Name

School Student Attends

Date of Birth

Gender

Race

Add 3rd Student?

3rd Student Information

First Name

Last Name

School Student Attends

Date of Birth

Gender

Race

Parent/Guardian Info

First Name

Last Name

Phone Number

Relation to student

Add 2nd Parent/Guardian?

2nd Parent/Guardian Info

First Name

Last Name

Phone Number

Relation to student

Parent Handbook Consent

I (the understated) agree that I have received the Accelerate to Great After-School Parent Handbook. I agree to follow and abide by the policies and procedures outlined in the handbook. I understand that it is my responsibility to read and know all of the policies and procedures outlined within this handbook. If I have any question(s) I will ask the Program Site Manager.

Initial

Parent handbooks for all programs can be found at www.waynemetro.org/afterschool

Media Release

I give permission for photographs and/or video to be taken of my child for program newsletters, program publications, news media, etc

YesNo

21st Century Literacy Enrichment Consent

I understand that 21st CCLC are dedicated, focused and committed to “Every Student Succeeds Act.” Therefore, staff and educators will need to be informed of any special needs my child may have. I understand that the information will be kept confidential and used for academic purposes or my child’s safety. If my child has a special need I understand that I should indicate below or discuss with the Site Manager so that my child may receive the proper assistance needed to succeed in the Accelerate to Great program. In addition, I give Wayne-Metropolitan CAA and its entity 21st CCLC and their partner’s permission to gather my child’s grades, test results, and other information related to his/her academic needs for evaluation purposes. This information will be kept confidential for the sole purpose of academic and social enrichment needs.

Initial

Virtual Program Release

, (“Student”) wish to receive academic and other support from Wayne Metro’s A2G – 21st Century Community Learning Center during the 2020-2021 School Year (“Services”). Typically, Services are provided to students face-to-face and on-site in a school building. However, due to COVID-19 and related precautions, such Services will now be provided to students on-line (“Online Services). The Online Services will be accessed via Google Meet and/or Zoom.

I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s).

I release Detroit Public Schools Community District from any and all claims, losses, damages, injuries, and liabilities and waive all rights in connection with my participation in Online Services. This Release will be governed by the laws of the State of Michigan. By signing below, I attest that I have read and I understand all of the terms of this Release and that I agree to be bound by all of them.

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

I warrant that I am the Parent/Legal Guardian of the above-named Subject and that I have the full legal right and capacity to sign this Release. I have read and I understand all of the terms of this Release and I agree to be bound by all of them on behalf of myself and my child/ward. I am aware that all sessions of Online Services will be made accessible to me, other parents or guardians of my child/ward, and District personnel by the Partner.

Signature:

Name:

Relationship to Subject:

Address:

Date:

2nd Student Virtual Program Release

I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s).

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

Signature:

Name:

Relationship to Subject:

Address:

Date:

3rd Student

I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s).

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

Signature:

Name:

Relationship to Subject:

Address:

Date: