VPAC Registration Form

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720.620.2316
Registration Materials

IF YOU ARE REGISTERING FOR VPAC PROGRAMMING, YOU ONLY NEED TO COMPLETE THIS FORM. IF YOU ARE REGISTERING TO ATTEND SCHOOL WITH VPAC YOU MUST PROVIDE: 1. Proof of Residency: Phone, utility or water bill, or lease agreement. 2.Proof of Age: Religious, hospital, or physician’s certificates; adoption record; parent affidavit; birth certificate; previously verified school records. 3. Prior transcripts/records
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720.620.2316
STUDENT REGISTRATION FORM
General Student Information
Name

First & Middle Name Last Name
Grade in 2021-22:

6 7 8 9 10 11 12
Gender:

Female Male Prefer not to say
Date of Birth (MM/DD/YYYY)

Month Day Year
Date
Race and Ethnicity
What is the student’s ethnicity?
Spanish culture or origin, regardless of race

Hispanic or Latino a person of Mexican, South or Central American, Cuban, Puerto Rican, or other Not Hispanic or Latino
What is the student’s race? (check all that apply)
Decline to state Asian African American or Native Hawaiian or other Pacific
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EDUCATION
What school did the student attend in the 2019-20 school year? Previous School Type:

Charter Public School Traditional Public School Private School Other:
Parent/Guardian Information
Who does the student live with? (Circle all that apply)

Mother Foster/Group Home Father Other (describe): Grandparents
Is there a legal custody agreement? (If “yes”**, you must submit a copy of the court document)

Yes No
**If you answered “yes" to the above, please indicate whether the custody agreement is:

Joint Custody Sole Custody Guardian
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720.620.2316
FAMILY INFORMATION
Parent/Legal Guardian #1

Mother Father Legal
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Cell Phone
Email
example@example.com
Is this person an emergency contact? ☐ Yes

Active member of the Armed Forces or on full-time National Guard duty? {yes}{no}
Parent/Legal Guardian #2
Parent/Legal Guardian #1

Mother Father Legal
Address

Address

Street Address Line 2

State

Zip
Work Phone
Cell Phone
E mail
example@example.com
Does this person live with the student? ☐ Yes☐No
Does the student have any siblings who also attend VPAC?

Yes No
If yes, who?
Which language does your child most frequently speak at home?
Has this student ever received formal English Language instruction through a class specifically for English Language Learners (such as ELD, ESL, etc)? {yes} {no}
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SPECIAL NEEDS QUESTIONNAIRE
Students Name

First & Middle Name Last Name
We need to know as much as possible about your child so that we can provide a program that meets his/her needs. It is very important for us to know if your child has received special education services in the past. The fact that your child has been in a special education program will NOT hinder acceptance at VPAC. It will aid us in serving your child in the best possible way.
If your child does have an IEP, under which classification does he/she qualify? Please check all that apply:
If your child is enrolled in this unschool program and has special needs, we will follow your desire in how to execute. We believe that families know what is best and will then meet with you to review the IEP and execute how you lead. VPAC is an independent unschool model that strongly believes in the right for parents to determine how their students learn. You agree that you are solely responsible for your child's educational experience and VPAC is not responsible for your child, rather a supporter of how you want your child to learn. The information that I have given above is correct to the best of my knowledge.
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720.620.2316
ATHLETIC CONSENT FORM
Name

First & Middle Name Last Name
Date of Birth

Month Day Year
Date
The undersigned has read and understands the material contained in this form and hereby authorizes the student named above to participate in physical education and extra-curricular sporting activities including, but not limited to recreational sports (basketball, football, etc.), gymnastics, tumbling, dancing, etc. while enrolled in VPAC.

By the very nature, athletic activities can put students in situations in which serious, catastrophic and perhaps fatal injuries may occur. These injuries could include, but are not limited to the following:

❒Sprains/strains

❒Head injuries

❒Unconsciousness

❒Disfigurement

❒Cuts/abrasions

❒Paralysis

❒Fractures

❒Loss of eyesight

❒Death

Students and parents must assess the risks involved in such participation and make their choice to participate inspite of those risks. No amount of instruction, precaution or supervision will eliminate all risk of injury. Although the school may suggest or recommend the use of certain equipment, the school does not guarantee that such equipment will be free from defects or protect the student from injury. By granting permission for your student to participate in athletic activities, you, the parent/legal guardian, acknowledge that such risk exists and assume these risks. Participation by your child is voluntary and is not required by the school. The undersigned has read and hereby agrees to holdVICTORY PROJECT-BASED ACADEMICS & CAREER, its employees, agents, volunteers and/or sponsors and anyother person, firm or corporation charged or chargeable with responsibility or liability,free and harmless from any and all claims, demands, damages, costs, expenses, loss of services, action and causes of action resulting from the use of facilities, equipment and participation by my student in the above named athletic activity, to the fullest extent of the law.
Parent/Guardian Printed Name
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Printed Name Parent/Guardian Signature
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STUDENT MEDIA RELEASE
Student First & Middle Name
Last Name
Date of Birth

Month Day Year
Date
VPAC requests your permission to reproduce through printed, audio, visual, or electronic means activities in which your pupil has participated in his/her educational program. Your authorization will enable us to use specially prepared materials to (1) train teachers and/or (2) increase public awareness and promote continuation and improvement of education programs through the use of mass media, displays, brochures, websites, etc. At most, we would use your child’s first name, last initial, and grade level. a. I, as a parent or guardian, of the above named pupil fully authorize and grant VPAC and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as “Recordings”), for the purposes stated or related to the above. b.I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil’s parent or guardian. c.I understand and agree that VPAC and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings. d.I understand and agree that VPAC and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above. e.I hereby release and hold harmless VPAC and/or its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney’s fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above. Granting permission is voluntary. By checking yes, I confirm that I have read and understand the release and I agree to accept its provisions.

Yes, I give my permission for my child’s name and photograph to be used by VICTORY PROJECT-BASED ACADEMICS & CAREER No ,I do not want my child’s name or photograph to be used byVICTORY PROJECT-BASED ACADEMICS & CAREER and/or its authorized representatives
Parent/Guardian Name
Parent/ Guardian Signature

Clear
Date

Month Day Year
Date
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720.620.2316
PASSENGER BEING DRIVEN PERMISSION SLIP
VPAC students may leave the premises of program located for a richer educational experience. Students may be driven by the transportation service, car services, or staff. All drivers will pass background checks and meet the requirements set by the State of Colorado. To facilitate these drives, we ask you to sign a permission form for the school year that gives your child permission to participate in the drives to other locations.

Students will always be accompanied by at least one VPAC staff member.
Date of Birth

Month Day Year
Date
Full Name
Please mark your response:

Yes, my child, named above, has permission to be driven during the 2021-2022 VPAC school year. No, my child, named above, does not have my permission to be driven during 2021-2022 VPAC school year.
Date

Month Day Year
Date
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STUDENT HEALTH RECORD
Name

First & Middle Name Last Name
Does your child have any of the following serious medical conditions?
Seizures

yes no
Asthma

yes no
Diabetes

yes no
Epi-Pen

yes no
Peanut Allergy

yes no
Allergies (please list allergies ie medications, food etc)
Please List Medications and Dosage
Does the student need to take medication at program? ☐ Yes** ☐ No If “yes”, please complete the medication administration request form, attached to this page.

Does the student wear a removable prosthetic device? If “yes”, where:

Are there any additional health problems the school should be aware of? If “yes”, please describe:{pleaseMark}

The information that I have given above is correct to the best of my knowledge. In addition, I understand that it is my responsibility to provide the school with a current version of the medication administration request form for each school year.
Signature

Clear
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MEDICATION ADMINISTRATION FORM
Student's Full Name
Date of Birth

Month Day Year
Date
If this box is checked, you do not need to complete the rest of the Medication Administration Form, however, your

My child DOES NOT need regular or occasional medication administered at the school.
Parental Consent

If your child does require medication at school, please check “yes” in each box to give your consent.
I give consent for the First Aid Administrator at my child’s school to communicate with the authorized healthcare provider and the pharmacist with regard to the provider’s written statement for administration of medication at school

yes no
I agree that, as the parent/guardian, I will provide the necessary medication, supplies and equipment.

yes no
I agree that, as the parent/guardian, I will notify the First Aid Administrator at my child’s school if there is a change in the student’s medication, health status, or authorized health care provider.

yes no
I agree that, as the parent/guardian, I will notify the First Aid Administrator at my child’s school immediately and provide new consent for any changes in authorized provider’s authorizations.

yes no
My child understands that if s/he is carrying an inhaler, that it is to be kept in a secure place and never to be shared with another student under any circumstances.

yes no
If your child needs regular or occasional medication to be administered at school, please complete the steps in the checklist below and return medication administration request form to the school.

1.Talk to your child’s doctor about making a medication schedule so that your child does not have to take medication while at school.

2.If your child is regularly taking medication for an ongoing health problem, even if he/she only takes the medication at home, give a written note to the school’s First Aid Administrator at the beginning of each school year. You must list the medication being taken, the current amount taken, and the name of the doctor who prescribed it .

3.If your child must take medication while at school, use the form provided to give permission from you and directions from your child’s doctor or other health care provider, who is licensed to practice in this state. Provide new, updated notes at the beginning of each school year and whenever there is any change in the medication, instructions or doctor.

4.As a parent/guardian, you must supply the school with all medication you child must take during the school day. You or another adult must deliver the medication to school, except medication your child is authorized to carry and take by him or herself.

5.All controlled medication, like Ritalin, must be counted and recorded on a medication log when delivered to the school. You or another adult who delivered the medication should verify the count by signing the log

6. Each medication you child must be given at school must be in a separate container labeled by a pharmacist licensed in the United States. The container must list your child’s name, doctor’s name, name of the medication and instructions for when to take the medication and how much to take.

7.Pick up all discounted, outdated, and/or unused medication before the end of the school year.
Parent/Guardian Printed Name
Name

First Name Last Name
Parent/Guardian Signature
Sign Here

Clear
Date
DateTime
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720.620.2316
STUDENT EMERGENCY INFORMATION AND RELEASE FORM
Student

First & Middle Name Last Name
Parent/Legal Guardian #1

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student ( check all that apply)

Legal Emergency Lives with Student
Title (mother, father, etc)
Parent/Legal Guardian #2

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Student ( check all that apply)

Legal Emergency Lives with Student
Title (mother, father, etc)
STUDENT RELEASE
Emergency Contact #1
Relationship to Student
Phone Number

Area Code Phone Number
Emergency Contact #2
Relationship to Student
Phone Number

Area Code Phone Number
Does your child have a sibling(s) that attends this school?

yes no
Name

First Name Last Name
EMERGENCY MEDICAL TREATMENT

The undersigned as parent, as parent/legal guardian of the student indicated on this card, a minor, hereby authorizes the principal or designee in whose care the student has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment and/or hospital care to be rendered to the student upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance if any required diagnosis, treatment, or hospital care and provides authority and power to VPAC, to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization shall remain effective until revoked in writing and delivered to VPAC, I understand that VPAC its officers, and its employees assume no liability of any nature in relation to the transportation of the student. I further understand that all costs of paramedic transportation, hospitalization, and any X-ray, or treatment provided in relation to this authorization shall be my sole responsibility as the student’s parent/guardian.
My child has medical conditions/ allergies that restrict physical activity or require special attention.

yes no
My student is currently taking medications.

yes no
Insurance Name: Group ID: Doctor Name/ Medical Office: Phone:
Insurance Name:
Group ID:
I certify that I have read and understood this form and do hereby give my authorization for emergency medical treatment, and all information is true and correct.
Should be Empty:

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Registration Materials

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STUDENT REGISTRATION FORM

General Student Information

Race and Ethnicity

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EDUCATION

Parent/Guardian Information

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FAMILY INFORMATION

Parent/Legal Guardian #2

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SPECIAL NEEDS QUESTIONNAIRE

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ATHLETIC CONSENT FORM

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STUDENT MEDIA RELEASE

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PASSENGER BEING DRIVEN PERMISSION SLIP

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STUDENT HEALTH RECORD

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MEDICATION ADMINISTRATION FORM

Parental Consent

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

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STUDENT EMERGENCY INFORMATION AND RELEASE FORM

STUDENT RELEASE

EMERGENCY MEDICAL TREATMENT