DYMON Youth Enrichment Programs
DYMON: Fall 2021 - Spring 2022
Introduction
Greetings Caregiver, We are excited about the opportunity to mentor your youth. Please fill out the application beneath. You will hear from a Staff Member in the next 48-72 hours!
Program Name
DYMON Non-Profit 501c3 Organization
Program Description
DYMON is a holistic program that creates fun and engaging ways to support student’s academics, youth development, and leadership skills. We will intentionally cultivate experiences where youth build self-confidence, healthy relationships, and know their true value and purpose. Our focus is youth-led and youth-supported initiatives.
Program Director Name
Edwina Freeman
Program Director Email Address
Edwinafreeman@dymon.org
Executive Director Name
Brittany Tyler
Executive Director Email Address
brittanytyler@dymon.org
Back
Next
Please Select Program for your Youth
*
Please Select
DYMON- H.G. Hill Morning Tutoring (7:30-8:30am)
DYMON- LEAD Brick Church After School(4-6pm)
DYMON- Madison After School (4-6pm)
DYMON- H.G. Hill After School (4-6pm)
Student Information
*
First Name
Last Name
Name Student would like to be called
*
Student Birthday
*
-
Month
-
Day
Year
Gender
*
Male
Female
Race
African American/Black
White
Hispanic/Latino
American Indian
Asian
Other
Student ID#(190)
*
School
Please Select
H.G. Hill
LEAD Brick Church
Madison
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a new home address( Moved in the last 6 months?)
*
Yes
No
Grade Level
*
5th Grade
6th Grade
7th Grade
8th Grade
Student Phone Number
Please enter a valid phone number.
Student Email
example@example.com
Back
Next
Parent/Guardian Information
Parent/Guardian 1
*
First Name
Last Name
Relationship to Student
*
Primary Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Lives with Student?
*
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Back
Next
Transportation
Transportation is NOT AVAILABLE for Morning care. Bus transportation is first come first serve and limited!
Transportation Needs
*
Bus Request
Car Rider
Bus Transportation Request Information
Student Address
Student Address Line 2
City
State / Province
Postal / Zip Code
Is the information above correct?
*
Yes
No
Transportation Permission
My student has permission to ride a Metropolitan Nashville Public Schools School Bus from school to my student’s regular bus stop to participate in extended school day activities. I understand that my student may be en-route on the school bus in excess of one (1) hour. I understand that transportation services may not be provided for my student if we reside in a parent responsibility zone. I further understand that services will not be provided on early release school days, snow days, or any other day school is not in session. My student and I understand that this service is a privilege, and further understand that bus service will be discontinued should the student misbehave or violate school system’s safety rules. My student and I have read the attached Bus Rider Rules and agree to abide by them.
Parent/Guardian Authorization
*
I give permission for student to be transported by the Metro Nashville Public Schools Transportation Department
I will decline the transportation services
Back
Next
Medical Information
Preferred hospital if your child needs medical care
*
Note: If not applicable add "N/A"
Primary Doctor Name
*
Note: If not applicable add "N/A"
Doctor Phone
*
.
Does your child has Medical Insurance?
*
Yes
No
Health Insurance Provider
Policy Number
Medicines?
*
Yes
No
Medicines
Allergies or Food Restrictions?
*
Yes
No
Allergies or Food Restrictions
Physical restrictions?
*
Yes
No
Physical Restrictions
Additional illnesses/conditions?
*
Yes
No
Additional illnesses/conditions
Additional Information you would like us to know about your Scholar
Back
Next
STUDENT PERMISSION FORM Nashville After Zone Alliance (NAZA) partner agencies, receive information from Metro Nashville Public Schools (MNPS) about the students that are enrolled in Backfield in Motion or affiliated programs. The programs utilize personally identifiable information (PII) from student’s school records to plan and provide high quality after school programming for your student. Information that is deemed as part of the student’s school record is listed below: School ID. School name Student number Last name First name Middle name Preferred name Birthdate Gender Grade level Address IEP Status (Presence of an IEP, and the dates that indicate if a new IEP is due) Note: MNPS will not share any additional information about your child’s IEP. The parent/guardian is the only person(s) allowed to disclose any additional information about the IEP. Daily Attendance record # of suspensions (in and out of school) Academic achievement data, such as: State summative assessment/ TCAP (if administered)Interim benchmark assessment/ MAPCollege and Career readiness assessmentsWIDA ACCESS for English Learners Class grades Access to devices (computer, tablet) and internet at homeThe information will be treated as confidential in agreement with the Family Educational Rights and Privacy Act (FERPA), will not be released to any other parties that are neither associated nor affiliated with NAZA, and will be used for the sole purposes to continue providing high quality after school programming to your child. NAZA personnel and its partners will be properly trained to protect your student’s Personally Identifiable Information (PII). Any PII that has been collected and maintained by NAZA partners agencies will be permanently destroyed at the end of the academic year.I give my permission to the Nashville After Zone Alliance and its funded providers, unless otherwise noted in the space below:To have my child participate in NAZA-funded programs and activities at my child’s school as well as other off-site locations throughout the NAZA system, as specified in this enrollment form, knowing that this might include special activities, such as off-site events, end-of-year celebrations, homework/academic help, and field trips, and realizing that some of these may take place outside of regular program hours.With the medical information provided in the program application in mind, to engage in all activities except as noted. To secure proper medical treatment for my child in the event of an emergency. If I or my emergency contact cannot be reached, I give permission for a physician to order routine tests and treatment for the health of my child. I give permission to a physician to secure treatment and/or hospitalize my child; after all emergency contact attempts have been made. To provide assistance in accessing devices and internet services when presented as a barrier for my child to participate in after-school and summer programs.To use in media releases to benefit NAZA and it's funded partners, photographs, creative work, quotes, videos, or other media which may include my child. I, the undersigned, understand, acknowledge, and agree:That I have read and understand the information provided in the Parent Consent form.That I will update any information I provided about my student in a timely fashion.That NAZA-funded and affiliated providers will request my child's records that may contain personal information (share demographics, grades, assessment, attendance, behavior/suspensions, IEPs and information about access to technology and internet at home) for the sole purpose of helping my child succeed in school and beyond.I therefore waive, with respect to these disclosures, any duty of confidentiality arising from Federal or State requirements.That participation in NAZA-funded programs and providing information about my child may involve certain risks. I assume all of these risks.That NAZA-funded providers will make themselves available to children, parents, and school staff and any concerns they might have.That NAZA-funded providers will protect the safety, interests, and rights of all individuals in the program. Therefore, each program will provide a parent/youth handbook or other program-specific information, including behavior policies and grievance procedures.That my child may be asked to complete surveys regarding the program for evaluation purposes.That I will not seek to hold NAZA or its funded providers responsible for any losses or damages whatsoever which I or my child may incur in connection with NAZA or its funded providers.That all program staff are employed by NAZA-funded providers, who are responsible for the operations of the program and supervision of their personnel. NAZA takes no responsibility for these operations or supervision.I, the parent or legal guardian give consent for Metro Nashville Public Schools to share my child's information, as described above, with NAZA staff and its funded and affiliated partners for the purpose of planning and providing high quality after-school programming to my child. I fully release and discharge MNPS and its employees from any and all liabilities arising out of or in connection with the above described data sharing relative to NAZA and NAZA partners. I reserve the right to withdraw my consent at any time by submitting a written notice of withdrawal of consent to NAZA or its partner.Do you provide permission?
I DO NOT provide permission
I DO provide permission
Signature
Clear
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform