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ASAP Online Registration 2018-2019
A physical signature will be required before your child begins participation in the program.
Email address *
Student First Name *
Your answer
Student Middle Initial *
Your answer
Student Last Name *
Your answer
Student Address - Street *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Student Phone Number
Your answer
Grade *
Parent/Guardian 1 (Name) *
Your answer
Lives with Student *
If No Please Provide Address (including City, State, Zip)
Your answer
Parent/Guardian 2 (name)
Your answer
Lives with Student
If No Please Provide Address (including City, State, Zip)
Your answer
Cell Phone # *
Your answer
Work Phone #
Your answer
My Student is allowed to walk home and/or check out of program (initial will be required in person) *
People Authorized to Pick Up Your Child (name, relationship, and phone number for each person) *
Your answer
Emergency Contacts - In case of a serious accident or illness, your child will be sent to an emergency medical facility. The parent/guardian(s) will be contacted immediately and thus held responsible for all expenses. The individuals below will be contacted should such an incident occur.
Your answer
Emergency Contact # 1 (name, phone, relationship to student) *
Your answer
Emergency Contact # 2 (name, phone, relationship to student) *
Your answer
Medical Information - The staff at ASAP encourage you to share your student’s medical information so we can ensure their safety while enrolled in our program. This is private information that is only required so we can be aware of any medical issues that might come about during our program.
Your answer
Food Allergies *
If yes, please explain
Your answer
General Allergies *
If yes, please explain
Your answer
Medical Conditions/General Medical Info *
If yes, please explain
Your answer
I give permission for my student's picture to be used for ASAP marketing initiatives (Initial needed in person) *Parent permission is required in order for your student’s picture to be used on behalf of ASAP. Our program utilizes pictures of our students for marketing purposes on our Facebook page, website, and various local newspaper articles. Media Representatives and ASAP staff may interview and photograph students involved in ASAP programs and activities as needed. Information obtained directly from students does not require parental approval prior to publication. Parents who do not want their student interviewed or photographed should direct their student accordingly. *
I give permission for my student to sign him/herself out of ASAP (initial needed in person) *ASAP must have parent permission for all students who are able to sign themselves out, otherwise we will keep them at our facility until they are picked up. If your student signs out, He/She may NOT return to the program that day, nor is ASAP responsible for your student after his/her departure. Upon conclusion of the the program at 6pm, families must arrange for transportation home. If attending a recreational or after­school activity separate from ASAP (sports, clubs, band, etc), we must have verbal or physical notice from the parent/guardian giving permission for the student to leave ASAP. He/She may return to ASAP after their activity has ended. By signing below, I authorize my child to sign him/herself out of ASAP. I understand my child may NOT return to ASAP that day, nor is ASAP responsible for my child after his/her departure. If you have questions please contact the Program Director. *
I give permission for ASAP Staff to access my child's schedule and Pinnacle Sign in/password codes (signature needed in person) *I understand that in order for the staff of my child’s school and the ASAP staff to work efficiently with my child, they will need to access schedule and assignment information. Most often my child will bring their homework and all necessary materials with them to ASAP, but on the occasion when they don’t, I understand that the tutors will be attempting to help him/her to complete work and may need to assist my child by investigating what assignments are due and the nature of the assignments. I give my permission for my child’s schedule and Pinnacle sign in/password codes.I am also aware that ASAP staff will be viewing my child’s homework site with my child on occasion in order to clarify assignments. By signing this form I allow ASAP tutors and staff to contact teachers and work with school staff if necessary to clarify an assignment and better assist my student with his/her academic needs. *
I give permission for ASAP staff to access my child's future academic information to track program success. (Signature needed in person) *In order to track the effectiveness of ASAP and to improve the services we offer ASAP staff would like to follow up with you, your student, and your student’s teachers to collect academic progress data. This data will include attendance, grades, and behavior information. This information may be used for grant proposals, in the case of data sharing all names and identifying information will be removed to protect you and your student.By signing this form I allow ASAP staff to contact future teachers and administrators staff to gather follow up data including attendance, grades, and behavior *
Student Behavior Contract: My child is willing to read, sign, and be accountable to the ASAP behavior contract before beginning participation in ASAP. *
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