The Scholars Project

Student Information

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Gender*

Race/Ethnicity*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Student Phone Number (if student has one)*

Area CodePhone Number

Student Email (if student has one)*

example@example.com

Please select all that apply.*

How did you hear about the Life Enrichment Group?*

Best day(s) and time(s) of the week to contact?*

This is a only a 4 week program. Participation and attendance is important! We are requesting for scholars to not miss more than 2 days of the program. If your student will have to miss more than 2 days, we do not recommend enrolling. Please list any dates that your student will not be able to attend.*

Lunches will be available to students who need them. Please check the weeks your student will need lunch.

Week of July 8thWeek of July 15thWeek of July 22ndWeek of July 29th

T-shirt size: Please include if it will be a child or adult size.*

Parent/Guardian Information

Name*

First NameLast Name

E-mail*

Cell Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Household size (# of adults and # of children)*

Does your child have any allergies? If yes, please describe and list here. *

Does your child have any chronic health/medical conditions that we should be aware of? If yes, please describe and list here. *

Does your child have any mental health conditions that we should be aware of? If yes, please describe and list here. *

Does your child have any patterns or history of misbehavior or class disruption that we should be aware of? If yes, please describe and list here. *

School*

SPS/ School ID Number*

Grade*

Free/reduced lunch?*

Does your student have any of the following?*

If you selected any of the options above, please provide more detail.

Any other information regarding school we should know?*

Favorite subject in school and why?*

Least favorite subject in school and why? *

This program does include reading, writing, and other academic enrichment activities. Please describe if your student will need support in these areas?*

I understand that, unless noted below; photos, video, or audio recordings of participant at L.E.G events or programming may be used without compensation, to promote the L.E.G programs. I understand that my child’s name may be revealed in descriptive text or commentary. Please initial.*

L.E.G has permission to take video/pictures of my child. Select one.*

YesNo

Signature of student*

Date*

Date

Signature of Parent/Guardian*

Date*

Date

Code of Conduct

(Please keep this page for your records; you do not need to turn in this page)

The Life Enrichment Group Code of Conduct is to ensure the safety of all participants and to encourage conduct and behavior that will result in each participant receiving the full benefit of
enjoyment and educational experience from this event. Participants are asked to consider both their underlying attitudes and the effects of their behavior in representing themselves, their communities, and the Life Enrichment Group program.

Program participants and facilitators are expected to abide by the stated rules for this event:
• Fully participate in all scheduled activities. Inform LEG Staff if you are ill.
• Conduct yourself in a courteous manner, being respectful to all speakers, adults, and
other participants. Use appropriate language, exhibit good sportsmanship, and act as a
positive role model. Turn cell phones off or on silent (no texting) during scheduled activities, workshops, and speakers.

• Display of overly affectionate attention between participants is prohibited.
The following dress code will be enforced for all individuals attending The Scholars Project
including facilitators:

1. Clothing: all clothing shall be neat, clean, acceptable in repair and appearance, and shall be
worn within the bounds of decency and good taste as appropriate for LEG events.

2. Articles of clothing which display profanity, products, or slogans which promote tobacco,
alcohol, drugs, sex, or advertise gang symbols or affiliation are prohibited.

3. Items of clothing which expose bare midriffs, bare chests, undergarments, or that are seethrough are prohibited. Halter tops, tube tops, and spaghetti straps are not appropriate.

Confidentiality:

1. No disclosing instructor and other participate personal contact information includes
(email, phone, zoom and business information

2. Provide LEG with email address for students to take notes and access Google doc
(online journal)

3. No sharing of information on other participants' private information unless given full disclosure by the individual.

Health Information: Does the participant require any accommodations for a disability in order to access or participate in activities?*

What have we forgotten to ask? Please provide in the space below any additional information about the participant that you think is important or that may affect his or her ability to fully participate in the program. Attach additional information if needed.

This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by me and/or an examining physician. If you fail to advise Life Enrichment Group of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a “need to know” basis with LEG staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

I voluntarily sign this authorization in consideration for permission for my child(ren) to participate in The Scholars Project. I have read it, and I understand its content and significance. Signature of parent/guardian Signature* Date*

For Youth
The following behaviors will not be tolerated:
• The possession or use of alcohol or illegal drugs, tobacco products, stolen goods,
weapons, and fireworks.
• Sexual, physical, or verbal abuse. Pornography materials of any kind.
• Disrespect or negative attitudes of any kind will NOT BE TOLERATED.
I have read the Code of Conduct and agree to abide by it.

I understand that I am responsible for my child’s behavior. I give permission to the staff in charge to administer the code. I understand that is asked to be accessed from the zoom session. I, blanks* have read the Code of Conduct. First Name* Last Name*

Signature* Date

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

School Information

Photo/video release

Code of Conduct