EmailMeForm
LINK Leaders Guardian Application 2018
Part A
Student Name
*
First
Last
Guardian Name
*
First
Last
Relationship to Child
*
Parent/Guardian Contact Information
Cell Phone
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Work Phone
###
-
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Home Phone
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Other Phone
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-
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Email
*
Confirm
Which phone do you prefer us to call first?
Cell
Home
Work
Other
Part B
Does your child have any food allergies, medicine allergies, or medical conditions? If yes, then please list and/or explain. Please include mild allergies.
The Village Learning Place’s programs seek to create an inclusive and welcoming environment that helps youth of all abilities. Everyone is welcome to enroll. If your student needs to have special accommodations made to allow him/her to participate, we will be happy to work with you.
Does your child receive any special education services (IEP, 504, speech, etc.) at school or other supportive services? If yes, then please explain to allow our staff to help your child be happy and successful this summer.
____________________________________________________________________________________________________________________________________________________
Part C
Emergency Contact Information
Please complete the chart below for all individuals to whom you the legal guardian gives permission to provide safe passage home and/or can pick up your child in case of an emergency.
If for any reason these individuals change, then please contact your child's LINK teacher.
Name
First
Last
Relationship to the Child
Parent
Relative
Family Friend
Phone
###
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###
-
####
Phone
###
-
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Name
First
Last
Relationship to the Child
Parent
Relative
Family Friend
Phone
###
-
###
-
####
Phone
###
-
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Name
First
Last
Relationship to the Child
Parent
Relative
Family Friend
Phone
###
-
###
-
####
Phone
###
-
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Name
First
Last
Relationship to the Child
Parent
Relative
Family Friend
Phone
###
-
###
-
####
Phone
###
-
###
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####
Head-of-Household/Household Family Status of Applicant:
Check the box that applies in one of the following two categories.
Head-of-Household/Household Family Status of Applicant:
*
Single Parent - Mother
Single Parent - Father
Related/ Two Parents (two-parent household with a dependent child or children 18 years old or younger)
Elderly (one-or-two-person household with a person at least 62 years of age)
Other (any household, including two or more unrelated individuals not included in above definitions)
If the legal guardian is registering the student, then is he/she a relative?
*
Please select
Yes
No
Is the youth being enrolled homeless?
*
Please select
Yes
No
Is the youth being enrolled in foster care?
*
Please select
Yes
No
Is the family a TANF recipient?
*
Please select
Yes
No
Part E
PERMISSIONS AND ALLOWANCES
As the legal guardian of
Student's Name
I give permission for my child to do or complete the following:
• to be photographed or videotaped by the VLP or its partners (e.g. Johns Hopkins/SABES, Single Carrot Theatre, Family League) for marketing, public relations, and educational purposes.
• to access the Internet in the computer lab under VLP staff supervision.
• to walk to the Margaret Brent Elementary/Middle school playground on an as needed basis, under close supervision of the VLP staff.
• to accompany VLP staff and his/her class on walking field trips in the community surrounding the VLP. Students will not travel unsupervised in the community during program hours.
• to be escorted home by persons that I list on this application as authorized to give SAFE PASSAGE HOME.
I will allow staff members of the Village Learning Place to:
• transport my child between the VLP and neighborhood locations within walking distance as needed
• give my child reading and math evaluations and assessments
• access my child’s school records, including test scores, attendance, behavior and suspension records, and applicable information concerning services my child receives such as IEP records, 504 plans, etc.
• conduct and have students complete program evaluations as pre-determined by program funders
• communicate with your child’s teacher or other school staff about academic performance and behavior
• provide on-site minor care for injury or illness
• provide immediate medical attention in an emergency by transporting my child to the nearest hospital or medical facility
I understand that with my support, my child must maintain a good attendance record, actively participate in all activities, and exhibit good behavior in order to remain in the program.
I release the Village Learning Place, Inc., its partner organizations, and employees from any and all claims or liabilities for any damages or injuries that may be sustained in connection with this program or in transporting my child to and from or during the program. I understand that the program ends at 4:00pm. I will make sure someone picks up my child or that my child can leave on their own by 4:00pm Monday through Friday.
Part F
BEHAVIOR, ATTENDANCE, AND DROP OFF/DISMISSAL POLICIES
Discipline
Respect for children, their unique personalities, and their feelings are important. We use a system of restorative justice to help students who are struggling with behavior.
As your partner, it is our goal to assist your child in developing self-control and socially acceptable behavior. The classroom teacher and Program Coordinator will keep you informed of any behavioral problems concerning your child. Every effort will be made to resolve any problems that occur.
Part G Permissions
I understand that with my support, my child must follow all policies and procedures contained within this application and within the LINK Family Handbook. I hereby agree to follow all policies in this application, and I certify that all information in this application is true to the best of my knowledge.
Parent/Guardian Name
*
First
Last
Date
MM
/
DD
/
YYYY
Parent/Guardian Signature
Clear
Use the mouse or your finger to draw your signature.
Feedback
This field is optional. Please include any feedback or questions you have.