Mosaic Sign-Up (Spring 2018)
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. *
Students are not allowed to switch clubs after the first week. It is important for students to take their choice of afterschool program(s)seriously. It is their responsibility to attend regulary. If a student misses more than (3) times, they will no longer be able to attend. Please check "yes" if the importance of attendance is understood. *
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
Monday
American Sign Language (ASL) - 2:45 - 4:15
Minecraft - 2:45 - 4:45
Improv - 2:45 - 3:45
Homework Club - 2:30 - 4:00
Club Sign-Up: Tuesdays
Tuesday
Baking and Cooking - 2:45 - 4:45
Stained Glass - 2:45 - 4:45
Movie Making - 2:45 - 4:45
Homework Club - 2:30 - 4:00
Club Sign-Up: Wednesdays
Wednesday
Sewing - 2:45 - 4:45
Garden Club - 2:45 - 4:45
Aikido - 2:45 - 4:45
Club Sign-Up: Thursdays
Thursday
Woodworking - 2:45 - 4:45
Mosaic Art - 2:45 - 4:45
Cosmetology - 2:45 - 4:45
Rock Band - 2:45 - 4:15
G.L.O.W. - 2:45 - 4:45
Homework Club - 2:30 - 4:00
Club Sign-Up: Fridays
Fridays
Row 1
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. *
Submit
Never submit passwords through Google Forms.
This form was created inside of The Southwest Vermont Supervisory Union. Report Abuse - Terms of Service - Additional Terms