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Olympia Learning Center
IMPACT Afterschool Program Parent Permission Form
Dear Parent/Guardian:
Your son/daughter would like to participate in the IMPACT After School Program at the Olympia Learning Center. This after school program is a result of an EEDA funded grant received by the Olympia Learning Center entitled Preparing College and Career Ready Graduates. There is no fee for participation in this after school program. Through participation in the program, students may be able to complete seat time at no cost to the student, credit recovery through E20/20, mentoring services, life skills enhancement through Overcoming Obstacles to Success evidence-based curriculum, as well as career and personal development.
The program days/hours are Tuesday through Thursday from 3:30 p.m. – 6 p.m. This is a voluntary program and students are expected to attend the program all three days the after school program is in session. Transportation will be provided. The program will take place on the Olympia Learning Center school campus.
In order for your child to participate in the above-mentioned after school program, Richland School District One requires parent/guardian consent. Your signature not only gives permission for your child to participate, but also authorizes Richland School District One to take photos and use video/audio footage of students who participate in the program. Please complete and return the bottom portion of this form if you choose to have your child involved in this field study.
Please return this consent form to Mrs. Coleman, Media Center or Ms. Smalls, Career Specialist
Please keep the top portion of this form for your reference.
IMPACT Afterschool Program
I give permission for (please print your student’s name) to participate in the IMPACT after school program at the Olympia Learning Center. The telephone number where I (please print parent/guardian name) can be reached in case of an emergency is . If I am unable to be reached, please contact (please print name and phone number of emergency contact).
PLEASE COMPLETE ALL INFORMATION BELOW
MEDICAL INFORMATION: Medication taken regularly:
Other Medical Problems:
INSURANCE INFORMATION: Insurance Company:
Insurance ID/Account #: Group#:
AUTHORIZATION: I authorize the school’s representative to transport, request and authorize treatment for my son/daughter in the event of an accidental injury or illness. I agree that I will not hold this person liable while he/she is acting according to these directions.
YOUR ADDRESS: ______CITY______ZIP______
Parent Email______
Parent/Guardian SignatureDate
Parent/Guardian (Print Name)
______Grade______ Student Signature Student (Print Name)