OHMS Inspire Fall 2023 TUESDAY

TUESDAY Robotics, Art & Music

Coda after-school programs for 6th -8th grade students at OHMS. Tuesdays at 2:30pm-5:00pm, from 9/12/23 to 12/5/23. Bus rides available for public school students within approved distance from school. Meals/Snacks will be provided and all programs are FREE!
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Student Age*
Student Gender (Required for Grant Purposes)*
Student Grade*
School*
School District Student Lives In (Required for Grant Purposes)*

Parent/Guardian 1*

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian 1 Phone Number*
Please enter a valid phone number.
As the parent/guardian, please identify your relationship to the student *
Parent/Guardian 2 (Emergency Contact will be requested later)

First NameLast Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Is your yearly income $35,000 or below? (Required for Grant Purposes)*

YesNo
Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code

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
Student Attendance - For greatest impact on the student and for purpose of our grants, regular attendance is very important.*

I understand that any student missing more than three 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.
Bus Announcement
Buses leave the school around 5:00 pm. If a child was signed up to ride the bus, 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 busMy 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
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 a Coda associated adult 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.
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
"Funding is provided by the United States Department of Education's Nita M. Lowey 21st Century Community Learning Center Program."

West Virginia’s 21st CCLC Program Focus Group Informed Consent Form for Parents or Guardians

(To be completed ONLY if you give permission for WVDE staff to interview your child during a site visit)
I understand that my child, will be participating in a focus group of students at their 21st Century Community Learning Center site. The West Virginia Department of Education (WVDE) is seeking feedback as part of the program monitoring system. Names and identifying characteristics will not be used in any publication of findings.
Individual Information provided from the focus groups will be held in strictest
confidence, and I understand that I am free to withdraw permission for my child’s
participation at any time by notifying the staff at my child’s before or after school
program, and that there will be no negative consequences from WVDE or from
the program as a result of this withdrawal. My signature on this consent form
indicates my understanding of the focus group. The program staff member’s
signature indicates that he or she has explained the purpose of the focus group
and to inform my child that he or she may withdraw from participation at any time
with no negative consequences. If you would like a copy of this form for your
records, please contact your Program Director. If you have any questions about the program, you may contact the after school program staff member named below at (304) 900-0096
Child's name (please print)
Signature

Clear
Date

MonthDayYear
Date
Name of Afterschool Program
21st CCLC Staff Member
Site Name
Should be Empty:

TUESDAY Robotics, Art & Music

Programs

Terms & Policies

Bus Announcement

Medical Release