Mosaic Sign-Up (Fall 2017)
Student's Name *
Your answer
Grade *
Parent / Guardian Name *
Your answer
Street Address *
Your answer
Email Address
Your answer
Home / Work Phone: *
Your answer
Cell Phone:
Your answer
Does your child have any allergies / health conditions? *
Your answer
Does your child have an IEP or behavior management plan? *
If yes, yes, please provide the name of their case manager so we can make necessary arrangements for your child’s success.
Your answer
Emergency Contact Name (OTHER than parent / guardian) *
Your answer
Emergency Contact Phone: *
Your answer
Discipline: Three Strikes” and you’re out for minor offenses. “One Strike” and you’re out for any physical/violent actions towards students/staff. By selecting "yes", I understand that all school rules apply accordingly. *
MEDIA RELEASE: My child may be interviewed /photographed /videotaped by the news/media/school or school district which may result in print, video, or web publication. *
MEDIA RELEASE: MAUMS or the SVSU may feature my child’s school work. *
I acknowledge that the Mosaic Program does not provide student supervision beyond 5:00pm *
Homework Club is available for 7th and 8th graders M,T & Th in room 1517. No registration is required and there is no fee.
Club Sign-Up: Mondays
GLOW (Gay, Lesbian, or Whatever)
Mosaic Marketplace
Club Sign-Up: Tuesdays
Movie Making (ends at 3:55pm)
Mystery Box Club
Club Sign-Up: Wednesdays
Field Games (ends 3:55pm)
Stained Glass
Open Studio (proposal required)
Club Sign-Up: Thursdays
Wood Shop
Rock Band
Club Sign-Up: Fridays
I, the parent / guardian of the child listed under "Student Name", agree that I have answered the above questions accurately to the best of my knowledge. By selecting "Yes", I agree that I have reviewed this form and my child may attend the selected Mosaic Programs. *
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