Northside Middle School
STARBASE 2.0 After-School Club
STARBASE 2.0 is a Department of Defense afterschool mentoring club that focuses on hands on STEM (Science, Technology, Engineering, and Mathematics), goal setting, and team-building activities. This club is designed to enhance student engagement in STEM subjects and provide the opportunity for students to explore enrichment activities in a safe environment. The club meets one day a week afterschool from 3:30 pm – 5:30 pm. The students will be teamed with a trained mentor and a teacher from their school. Attached are the Student Application, Club Contract, Emergency Health Form, and Student Survey. Please complete these forms with your student and return to the school staff or STARBASE 2.0 teacher sponsor. If you have additional questions, please contact
Benita Blackwell – 2.0 Program Coordinator -
Brandon Jones – Program Assistant -
LaTondra Oliver– STEM Project Manager -
Ph. # 478-926-1986
STARBASE 2.0 Club Application
Student Name: ______Date of Birth: ______/______/______
School: ______Homeroom: ______Grade: ______
Gender: __Male __Female Student ID# (Lunch Number):______
Race/Ethnicity: Black____ White____ Asian____ Hispanic_____ Latino_____ Indian______
Other______- please write it in if it’s not listed:______
Address ______
______Phone: ______
City State Zip
Previously participated in the STARBASE 5th grade program? Yes_____ No____
Previously participated in STARBASE 2.0? Yes_____ No____
Contact #1: Name ______Phone: ______
Email: ______Relationship ______
Contact #2: Name ______Phone: ______
Email: ______Relationship ______
Transportation will not be provided. Please check one of the following:
____ The student will walk home. ____ The student will be picked up.
I am aware that submission of this application does not guarantee my student a slot in the STARBASE 2.0 Afterschool Program. My studentwill receive an acceptance letter if he/she has been selected.
Parent/Guardian Signature ______
Date______/______/______
STARBASE 2.0 Club Contract
Attendance Contract:
In order to remain an active participant of the afterschool club, you must attend regularly. Students with excessive unexcused absences will be dismissed from the club. The attendance policy is required to ensure our club goals are met for the year. Students must provide a written excuse to the Club Coordinator for afterschool absences. Students are expected to maintain a 75% attendance rate. The club will operate one day a week for 2 hours each day.
Student’s Signature ______Date ______/______/______
Parent/Guardian Signature ______Date ______/______/______
Behavior Contract
I, ______agree to manage my behavior daily at this middle school. I will refrain from speaking inappropriately to faculty, mentors, peers, and my parents/guardians. I will keep my hands, feet, and objects to myself and work hard academically. I will check in with the Club Coordinators daily and report any concerns or problems.
Student’s Signature ______Date ______/______/______
As the parent of ______, I promise to support the club’s discipline policy and encourage my child to follow the club rules. If I have concerns I will contact the Club Coordinator. I understand that my child will receive a warning, a phone call home, and will then be dismissed from the program.
Parent/Guardian Signature ______Date ______/______/______
STARBASE 2.0 Emergency Health Form
Are there any health problems we should be aware of? If so, please list them and any precautions that should be taken. ______
Please provide us below with any specific instructions you would like us to follow in case of illness or accident. ______
In case of emergency, notify: Name ______Phone # ______
Hold Harmless Agreement
The undersigned hereby acknowledges that participation in recreational activities involves inherent risks of physical injury, illness, or loss of personal property and assumes all such risk. In the event of an accident, illness, or injury, and the person above cannot be reached; I hereby give STARBASE ROBINS personnel permission to take action as deemed necessary in the best interest of my child. The undersigned hereby agrees that for the sole consideration of STARBASE ROBINS, allowing the participant in programs for which or in connection with which the program has sponsored or made, available any equipment, facilities, grounds or personnel for such programs or activities, the undersigned does hereby release and forever discharge STARBASE ROBINS, its members, officers, agents, and employees for all claims. I also understand that the STARBASE ROBINS staff reserves the right to terminate the participation of any student when it is deemed in the best interest of either the student or the STARBASE ROBINS Academy.
Parent/Guardian Name: ______
Signature: ______Date: ______/______/______
Student Photo Release Agreement
The STARBASE ROBINS staff takes numerous photos of students involved in all our activities. We sometimes use these photos in promotional materials for the STARBASE ROBINS program, such as brochures, newsletters, or videos. In order to include your child’s photo in any STARBASE ROBINS project, we must have signed your permission. If you agree to such use, please sign below.
I hereby grant permission for my child to appear in photograph, video, or digital imagery that will be used by STARBASE ROBINS. STARBASE ROBINS will hold any and all rights to include these images, in any format or media, and grant permission for its use in outside publications, including non-government television or cable stations. Student images will not be used for commercial purposes.
Signature of Parent/Guardian: ______Date: _____/_____/_____
Please return these forms to the school or STARBASE 2.0 teacher sponsor.