Xtreme Challenge Registration
2013/2014 School Year
Omak School District
P.O. Box 833
Omak, Washington 98841
Wendy Hensarling (509) 557-5920/(509) 322-1917 Site manager Middle School
Student First Name: ______Last______
Please Print
Date of Birth: ______Grade ______Age: ______Gender M F
Students Ethnic Background: Hispanic - Native American - Asian - African American - Caucasian – Other
Mailing Address: ______
Physical Address: ______
Parent Name: ______Contact Number: ______
Parent Name: ______Contact Number: ______
Emergency Contact ______Contact Number: ______
Is this person authorized to pick up your child? Yes No
Emergency Contact ______Contact Number: ______
Is this person authorized to pick up your child? Yes No
Emergency Contact ______Contact Number: ______
Is this person authorized to pick up your child? Yes No
Date of last doctor visit: ______
Any health concerns: ______
It is important that both students and families are aware of all program guidelines. Please go over all program rules and expectations on the back of this form with your child. As a family you will need to decide on the best form of transportation for your home situation. Select one of the following. Be sure your child is aware of how you expect them to get home. Remind them that they MUST adhere to this plan for safety reasons.
____I will provide my child with transportation after the program.
____My child will use bus transportation.
____My child will walk home after the program.
Program Guidelines
Code of Behavior:
· Participants will follow expectations set forth in the student handbook for the site they attend. This includes all discipline guidelines and procedures.
· Participants are responsible for treating school equipment and supplies with respect.
· Participants who are ill are not eligible to attend OCS programs.
· Participants are expected to treat staff, peers and volunteers with respect.
· Participants should attend activities with an open mind and a willingness to learn new things.
· Participants are expected to honestly respond to activity surveys, which will help guide OCS program choices.
Fee Guidelines:
· Xtreme Challenge is a free, grant funded program.
· Some classes may require small fees if extra projects are planned.
· Some classes must meet a minimum enrollment number to be held.
Please sign the spaces provided that apply to you and your child.
We like to promote and publicize student accomplishments in OCS classes and community events through print, photos and video footage. Parental permission is required before releasing images of your student for these purposes. Please indicate by signing below giving OCS permission to use photos and /or video footage of your child for publicity purposes.
Signed: ______
· I give OCS permission to use photos and /video footage of my child.
Program includes a snack and homework time 3:00-3:45. Students who are involved in sports
are encouraged to attend the snack - homework portion of the program. We also encourage parents of enrolled students to take classes. Classes are from 3:45-5:00 Tuesday-Friday. Monday schedule is yet to be determined, but will start at the early release time.
Enrollment is currently open to all students. Our grant specifically targets those students who may be struggling in school or have not passed all parts of the state test. We are required to track student’s grades and test scores. This information is used to better serve our student needs and to adjust programs for the academic benefit of students.
Parent/Guardian Signature Date
Students will participate in additional activities that include walking field trips. Your signature below gives your student permission to participate in walking field trips off school grounds.
Parent/Guardian Signature Date
OMAK COMMUNITY SCHOOLS
XTREME CHALLENGE
WALKING FIELD TRIP PERMISSION SLIP FOR 2013-2014 SESSION
Students during different activities and classes may go on a walking field trip.
Your signature below gives your student permission to participate on walking field trips.
Parent or guardian’s signature date
Student’s name