Program Enrollment Form Semester 1
2020 Middle/High School Out-of-School Time - Hiyupo Alliance Programming
Untitled Title
STUDENT INFORMATION
Student Full Name (first, last): *
Date of Birth: *
MM
/
DD
/
YYYY
What Grade is the Student in? *
Gender:
Clear selection
Tribal Affiliation/Ethnicity:
Has the Student been in any other OST/Hiyupo Programming before? if so which ones:
PARENTS / GUARDIAN INFORMATION
Parent/Guardian Name(s):
Relationship(s) to Child:
Cell Phone Number(s):
Email Address:
MEDICAL / SPECIAL NEEDS INFORMATION
Does the student have any special limitations or concerns? If please specify:
What Hiyupo Program(s) is the Student interested in? *
Required
Program Participation Agreement
I understand that the NACA Out-of-School Time program staff are responsible for maintaining a safe, educational, and a fun virtual learning environment. If my child’s behavior is disruptive or is in violation of the NACA school and out-of-school time program policy, he/she may be dismissed from program. Further, I understand that my child will adhere to the student responsibilities and expectations stated in the student agenda/handbook. By signing (typing full name)below, you agree to the provisions of the NACA Hiyupo Alliance OST Program.
Full Name and Date: *
If you have any concerns/questions please contact:
Hiyupo Alliance Coordinator- Anthony “Antro” Shemayme
shemayme@nacaschool.org

Head of School- Howard Humetewa
humetewa_h@nacaschool.org

** This enrollment form is for Semester I (October 2020-December 2020). Parents/ Guardians will have to fill out a new enrollment form for Semester II (January 2021-May 2021).
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