MHC After 3 High School Application School Year 2024-2025

MHC After 3 - High School

Application for Admission
c/o Patrick Henry Community College

645 Patriot Ave. Martinsville, VA 24112

276-656-5489 mhcafterstaff@gmail.com

P&HCC is an EEO institution.
SDI 2024 / School Year 2024- 2025
Student's Full Name*
Home Phone #
Student Cell Phone Number
Student Email
example@example.com
Mailing Address: *
City*
State*
Zip Code*
Student Lives With (Name)*
Relationship To Who Student Lives With*
Student Birthdate*

MonthDayYear
Date
Sex*

MaleFemale
Gender Identity*

MaleFemaleNon-Binary
School Attending for 2024-2025 School Year*
Does your child have an IEP or a 504 Plan?*
Grade level for Fall 2024*

Grade 9Grade 10Grade 11Grade 12
Free or Reduced Lunch

YesNoDid Not Apply
Adult T-Shirt Size

SmallMediumLargeExtra Large
Ethnic Origin*

American IndianHispanicAsianAfrican AmericanWhiteMulti-RacialOther
PARENT/GUARDIAN INFORMATION *****Must be completed and signed by a parent****
Parents or Guardians Name:
Parent or Guardian 1 Name*
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email*
example@example.com
Parent 2 or Guardian 2
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Emergency Contact Name 1 (Required):*
Relationship to child. *
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Emergency Contact 2 (Required)*
Relationship to child. *
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Who is authorized to pick up your child? *
Relationship to child. *
Who is authorized to pick up your child? *
Relationship to child. *
Authorized to pick up your child.
Relationship to child. *
Is there anyone who is UNAUTHORIZED to pick up your child? (Official documentation is needed)
Relationship to child*
Is there anyone who is UNAUTHORIZED to pick up child? (Official documentations is needed)
Relationship to child*
STUDENT MEDICAL INFORMATION *****Must be completed and signed by a parent****
Family Doctor or Clinic*
Phone Number*

Area CodePhone Number
Insurance Provider*
Policy Number
Please indicate allergies and medical conditions of your child*
Does your child experience motion sickness?*
Is your child a proficient swimmer?*
Are there any foods your child should not eat?*
Does your child have any physical limitations?*
Does your child require an epi-pen?*
List any medications your child is currently taking.*
Does your child have any special needs of which staff needs to be aware? *
Yes, MHC After 3 staff may perform basic first aid on my child to such as applying a band aid and providing a cold packYes, please call me for authorization if my child is requesting over-the-counter medications such as pain relivers or motion sickness tablets as well as feminine hygiene products as needed. *MHC After 3 does not have all medications or feminine hygiene products. Parents and students should not rely on the program to provide these items.Please DO NOT photograph my students for program documentation and promotion.
Parent Agreement:
I understand that the information I have provided here is for the use of MHC After 3/Patrick Henry Community College and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesses, or injuries which may result from participation. I allow MHC After 3/Patrick Henry Community College and partner agencies to take and publish pictures for program documentation and promotion. I give my permission for MHC After 3/Patrick Henry Community College to review my child’s school records and IEP/504 Plan for the purposes of recording grades, reviewing test performance, behavioral information and reviewing school attendance rates. Be it known that I, as parent/guardian of the named student, hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in an MHC After 3 sponsored event or field trip.

Yes, my child has permission to participate in fieldtrips, activities and events sponsored by MHC After 3.

I understand MHC After 3-21CCLC center operates as a teen drop-in center and is therefore exempt from VA Childcare Licensing as a daycare center. MHC After 3 operates engaging youth development programs daily from 3:30-6pm and during summer camps. All participants are advised to stay in the designated MHC A3 meeting area at all times; however, we cannot legally require a participant to stay at MHC After 3. MHC After 3 teen center will operate under the drop-in drop-out policy where participants can sign in to arrive and sign-out with notice of pick-up/or destination at their request. MHC After 3-21CCLC accepts that is assumes responsibility for the supervision, protection, and well-being of several children with disabilities who are mainstreamed and shall not be subject to licensure.
Parent's or Guardian's Name: Print*
Parent's or Guardian's Signature:

Clear
Date

MonthDayYear
Date
Student Agreement:
I would like to be a participant in the MHC After 3 Program. If I am accepted into the program, I agree to abide by ALL of the rules and regulations of the program, and participate in all activities. I will be respectful to staff and peers participating in the program on and offsite. I understand that violation of any of these may result in my suspension from the program.
Student Signature*

Clear
Date

MonthDayYear
Date
FOR OFFICE USE ONLY: Date Rec’d by MHC@3:
Date Rec'd by MHC@3:

MonthDayYear
Date
Rec'd By:
I would also like to register for Educational Talent Search for additional service and programming.
Should be Empty:

MHC After 3 - High School

SDI 2024 / School Year 2024- 2025

Parents or Guardians Name:

Parent Agreement:

Student Agreement: