Application for Admission
to MHC After 3 – Middle School
c/o Patrick HenryCommunity College
645 Patriot Ave. Martinsville, VA 24112
276-656-5489
Full Name: ______Home Phone #: ( )______
Name Student Goes By: ______Student Cell Phone # ______
Student Email Address: ______Parent Email: ______
Mailing Address: ______City: ______State: ______Zip:______
Birthdate:______Male______Female______School : Current Grade:______
Free or Reduced Lunch: Yes ______No ______Did Not Apply ______T-shirt: AdultS ____ M____ L____XL______
Please indicate the site(s) you would like to attend during the school year:
____Bassett Community Center (Mon-Fri) ____Fieldale Community Center (Mon-Fri) ____ FC Middle School (Mon-Thur)
ETHNIC ORIGIN
American Indian Hispanic Asian African American White ___Multi-Racial ___Other
STUDENT: PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOURSELF
Are You Enrolled in Other After School Programs?
[ ] No [ ] Yes The Program Name Is ______
Do you have any special needs of which staff needs to be aware?______
______
Describe yourself in 10 words or less: ______
______
What do you like about school: ______
What clubs/sports/activities do you participate in currently: ______
______
What do you like?
Rev 4/13 BSL
___Sports______
___Dancing
___College Exploration
___Music
___Leadership Skills
___Outdoor activities/Hiking
___Painting
___Communication Skills
___Summer Camps
___Drama
___Engineering
___Trying new things
___Career Exploration
___Science
___Going new places & making friends
___Social/Cultural Activities
___Poetry/Creative Writing
___Water Sports (Canoe/Kayak/Fishing)
___Board Games
___Art
___Culinary Arts (Cooking)
___Rocketry/Robotics
Other:
______
______
Rev 4/13 BSL
PARENT/GUARDIAN INFORMATION *****Must be completed and signed by a parent****Student Name ______School ______
Yes, my child has permission to participate in fieldtrips, activities and events sponsored by MHC After 3
Female Parent/Guardian’s Name:______
Home Phone:______Work Phone: ______Cell Phone: ______
Male Parent/Guardian’s Name:______
Home Phone:______Work Phone: ______Cell Phone: ______
Emergency Contact Name:______
Home Phone:______Work Phone: ______Cell Phone: ______
Please indicate if you would be interested in receiving information concerning our Parent’s Advisory Committee: Yes No
Family Doctor or Clinic: ______Phone: ______
Insurance Provider: ______Policy Number: ______
Please indicate allergies and medical conditions of your child ______
______
List any medications your child is currently taking ______
______
Parent Agreement:
I understand that the information I have provided here is for the use of MHC After 3 and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesses, or injuries which may result from participation and allow them to take pictures for program use. I give my permission for MHC After 3 to review my child’s school records for the purposes of recording grades, reviewing test performance and reviewing school attendance rates.
Be it known that I, as parent/guardian of the named student,hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in an IMIN/MHC After 3 sponsored event or field trip.
Parent's or Guardian's Name: ______(print)
Parent’s or Guardian’s Signature: ______Date______
Student Agreement:
I would like to be a participant in the 2013 MHC After 3 Ultimate Summer Camp Experience. If I am accepted into the program, I agree to abide by ALL of the rules and regulations of the program, and participate in all activities. I will be respectful to staff and peers participating in the program on and offsite. I understand that violation of any of these may result in my suspension from the program.
Student Signature: ______Date ______
FOR OFFICE USE ONLY:
Date Rec’d by MHC@3: ______Rec’d By: ______
Rev 4/13 BSL