OHMS Inspire Spring 2022

FPK8 (3rd-4th) Inspire Application

The following registration form is for 3rd - 4th grade students at Fayetteville PK-8. Programs run Feb 23 - May 4. We are there to help you succeed! Bus rides are available for those within approved distance from school. Snacks provided.
Student Name *

First Name Last Name
Student Email
example@example.com
Date of Birth *

Month Day Year
Date
Student Age *
Student Grade *
School *
School District Student Lives In (Required for Grant Purposes) *
Student Ethnicity (Required for Grant Purposes) *
Student Gender (Required for Grant Purposes) *

Parent/Guardian 1 *

First Name Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian 1 Phone Number *
Please enter a valid phone number.
Does this phone receive text messages?

Yes No
Parent/Guardian 2

First Name Last Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Does this phone receive text messages?

Yes No
Is your yearly income $35,000 or below? (Required for Grant Purposes) *

Yes No

Bus Announcement
Buses leave the school around 5:20 pm. If a child is on the bus list (if you selected “My child will be riding home on the bus" below), a signed note from the parent/guardian must be provided each time they will NOT be riding the bus home. BUS STUDENTS MAY NOT WALK OR CAR RIDE WITHOUT WRITTEN PERMISSION FROM PARENT/GUARDIAN.
Bus Info *

My child will be riding home on the bus My child will NOT be riding home on the bus
If your child will be riding the bus home, what bus number do they normally ride? blanks Where is their bus stop? blank
Address *

Street Address

Mailing Address

City State / Province

Postal / Zip Code
Signature

Clear

Terms & Policies
Loaned Instrument Policy Our instrument distribution system is designed to meet the needs of students within Coda Mountain Academy. At the beginning of each semester, a labeled instrument will be loaned to the student (should they need to borrow one) and a record will be made to identify which instrument goes to each child. While it is free to be loaned, it is required that the instrument be well cared for and returned at the end of each semester in the same condition it was loaned. Failure to properly take care of the Coda loaned instrument and return it at the end of the semester, unless explained and agreed upon by Coda administration otherwise, may result in a fine equivalent to the cost of the loaned instrument or the cost of repairs. *

I have read and agree to the above stated policy
Liability Waiver: I am aware that my child will be exposed to others including, but not limited to, Coda staff, students, interns, teachers and volunteers. In the chance that my child is exposed to COVID-19 or any other contagious disease, there is a risk of illness, permanent disability, and even death. In the event that any issue listed above were to occur, I agree to not sue nor seek any legal action, neither would Coda Mountain Academy, supervisors, staff, volunteers, interns, nor teachers will be held accountable. *

I understand and acknowledge the liability waiver written above and that Coda Mountain Academy nor any supervisor, staff, volunteer, intern nor teacher will be held accountable for the risk of exposure to COVID-19 or any other liabilities.
Student Attendance *

I understand that any student missing more than two classes without a valid reason and a written parent or doctor excuse may be excused from the program.
Photo Waiver: Understanding that Coda photos and videos are important to promote public awareness, access future scholarship funding and reach more youth, I hereby consent for my child (or myself if 18 or older) to be photographed and/or videoed for Coda Mountain Academy. The resulting photographs or videos may be subsequently used without compensation to me by Coda Mountain Academy, or third parties for publications (including web sites), advertising, Facebook and/or publicity purposes at the discretion of Coda Mountain Academy. Some photos and videos will be used in the year end grant report. I waive the right to inspect or approve the finished photograph, video and/or publication use. *

I, parent/guardian, consent to the above stated photo/video waiver for Coda. I, parent/guardian, DO NOT consent to the above stated photo/video waiver for Coda.
Medical Release
Does Your Child have any Allergies? *

Yes (please explain what Allergies below) No
Food Allergies *
Drug Allergies *
Any medical problems and/or medications that we should be aware of: *
Emergency Contact Person- this is who we will contact if we CANNOT reach Parent/Guardian 1 or Parent/Guardian 2 *
Emergency Contact Phone Number *
Please enter a valid phone number.
Emergency Contact Relationship to student *
Release Form *

I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy. In the event of injury, accident, illness or other emergency while participating in the after-school program, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize Esther Morey, Robert Morey, Jessica Moneypenny, Eric Snuffer or an associated adult supervisor to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider. I further authorize disclosure of medical information by a treating physician to Esther Morey, Robert Morey, Jessica Moneypenny, Eric Snuffer or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Signature

Clear

This program is funded through the Nita M. Lowey 21st Century Community Learning Center Program by the U.S. Department of Education through the WV Department of Education. During Site Visits, 21stCCLC Staff may interview students attending the afterschool program to learn the effectiveness of our programing. A signed parent consent form must be collected in order for the child to participate in the interview. *

I do give permission for 21st CCLC staff to interview my child (CONSENT FORM MUST BE COMPLETED) I DO NOT give permission for 21st CCLC staff to interview my child
WVDE 21stCCLC staff would like to send a Survey to your child's teacher to ask about student engagement in our program. If this is approved by you, then you need to do nothing. If you do not want your child's teacher to participate in the Teacher Survey, you must sign the Consent Form and send it back to us. *

I do give permission for 21st CCLC to send the Teacher Survey to my child's teacher I DO NOT give permission for 21st CCLC to send the Teacher Survey to my child's teacher (CONSENT FORM MUST BE COMPLETED)
"Funding is provided by the United States Department of Education's Nita M. Lowey 21st Century Community Learning Center Program."
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FPK8 (3rd-4th) Inspire Application

Bus Announcement

Programs

Terms & Policies

Medical Release