student registration form | 2013.2014
General Information
Student Name:Last / First / M.I.
Date of Birth: / Grade:
Address:
Street Address
Home Phone: / ( ) / Alternate Phone: / ( )
E-mail Address:
Parent/Guardian Name:
Last / First
Emergency Contact: / Emergency Phone: / ( )
Health Information/Medical Concerns (list any severe medical needs/allergies/dietary needs):
Please check all that apply.
I give permission for my child to be interviewed, identified, and/or photographed/filmed for use in program publications including, but not limited to, publication via website or other technological publications, videos, newspapers, radio, or television.
I give permission for my child to walk home after class.
I give permission for my child to take the MTD home after class.
My child will be picked-up by a parent or guardian after class.
My child needs transportation home via First Student bus. Transportation provided Monday-Thursday only. No transportation on Friday. (Child must meet the following requirements for transportation: Qualify for free/reduced lunch and not have a direct MTD route home.)
In the event of a medical emergency, your child will be taken by ambulance to the closest hospital or trauma center. All medical fees are the parent’s responsibility. Your permission is requested for school personnel to sign any medical forms that are needed for the purpose of assuring that emergency treatment can begin as soon as possible. Please sign this request, thereby granting your permission for school personnel to act on your behalf in the case of a medical emergency. Every effort will be made to contact parents prior to exercising the authority contained in this form.
If a student has an unexcused absence or is suspended from school, he/she may not participate in any activity on that day. In the case of an excused absence, a student must have been in attendance for at least three (3) periods the day he/she is to participate in an activity.
In order to participate in 21st Century Community Learning Center activities, students must follow Urbana High School and District rules and procedures as outlined in the UHS Student/Parent Guidebook. By singing this form, the parent/guardian also grants permission to monitor grades and standardized tests while the student is enrolled in the program.
Parent Signature: X Date:
Keep a copy of this form for your records. If your first choice is not available, you will be contacted. Please list all classes you are interested in taking on the lines below (in order of preference).
Course Information
1. Course Title: / Day: / 3. Course Title: / Day:2. Course Title: / Day: / 4. Course Title: / Day:
If your class requires additional costs, please make checks payable to Urbana School District 116.
Return this form to Dr. Velazquez in the Main Office (Room 2111) or email to .
SESSION 1 REGISTRATION DEADLINE: MONDAY, September 23, 2013
21ST CENTURY COMMUNITY LEARNING CENTER PROGRAM POLICIES
Student Expectations:
Every student has the right to learn and participate in the program.
Students are expected to follow all Urbana High School and Urbana School District expectations and rules regarding student behavior.
Students understand that parents/guardians will be notified if they engage in inappropriate behavior.
If a student is referred to the 21st Century Community Learning Center Coordinators for behavior problems, a parent will be notified by phone or a home visit. A parent conference may be scheduled.
Students must follow their 21st CCLC class schedule and be accounted for or they may be asked to leave the program.
Students who are not meeting these expectations may be removed from the program, and attendance in later program sessions will be re-determined by staff and administrators.
Attendance Policy:
Students are expected to attend classes regularly.
Students missing more than two consecutive classes may be dropped from the class, unless excused by program staff in advance. After three weeks of non-attendance in the program, a parent/guardian will be notified, with possible removal from the program.
Students who do not attend at least four class periods during the school day will not be allowed to attend the program, unless medically excused or attending a school sponsored event.
Parent Permission to Monitor Grades and Attendance:
Parents give permission to the Urbana High School 21st Century Community Learning Center staff to monitor student’s grades, school attendance records, and student standardized test results as needed.
Transportation:
Students who do not ride the MTD, First Student bus, or no do not walk, must be picked up by their rides NO LATER than 5:30pm. Chronic tardiness of a ride can also lead to dismissal from the program, unless prior arrangements have been made with program staff.
Funding provided by the 21st Century Community Learning Centers Grant, FY14