Excel Fall-Spring 2023/24

EXCEL Registration
The following registration form is for 3rd - 5th grade students at Fayetteville PK-8 on Mondays.

WHEN: October 2nd- November 13th from 3:20 PM - 5:30 PM.

WHERE: The Coda Center; 2859 Maple Ave. Fayetteville, WV 25840

(Located beside Fayetteville Christ Fellowship)

COST: FREE!!!!

GRADES: 3rd-5TH

*Coda Programs are provided several days a week and students are encouraged to attend as many of these as possible*

Free Bus rides are available from FPK8 to The Coda Center and back home for all public school students within the FPK8 school district.

Free Meal/Snacks provided.

Please email or call Coda Mountain Academy at info@codamountain.com or (304) 900-0096 with any questions.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Student Age*
Student Grade*
School*
School District Student Lives in (For Grant Purposes)*
Student Ethnicity (For Grant Purposes)*
Student Gender (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.
Does this Phone receive text messages?

YesNo
Parent/Guardian 2

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

YesNo

Bus Announcement

Busing will be provided from FPK8 to the Coda Center on Maple Avenue and will also be available to take students home after programming around 5:20 pm. If a child is on the bus list (if you selected “My child will be riding home on 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*

I give permission for my child to ride to the Coda Center from FPK8I DO NOT give permission for my child to ride to the Coda Center from FPK8
Bus Info*

My child will be riding home on the busMy child will NOT be riding home on the bus
Student's Address*

Street Address

Mailing Address (If Different)

CityState / Province

Postal / Zip Code

Terms & Policies
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 or guardian, consent to the above stated photo/video waiver for Coda.I, parent or guardian, DO NOT consent to the above stated photo/video waiver for Coda.
Medical Release
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

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 teacherI DO NOT give permission for 21st CCLC to send the Teacher Survey to my child's teacher (CONSENT FORM MUST BE COMPLETED)
This program is partially funded through the Nita M. Lowey 21st Century Comminuity Learning Center Program by the U.S. Department of Education through the WV Department of Education.

Evaluation of West Virginia’s 21st Century Community Learning Center Program

Parent / Guardian Denial of Consent

(To be completed only if you DO NOT give permission for WVDE to send a survey to your child's teacher and if the student is in 5th grade or lower)
I understand that the afterschool program my child will attend will be evaluated by the West Virginia Department of Education (WVDE The purpose of the evaluation study is to find out how well the program is working. What the WVDE learns from this study may help improve the program in the future. Later this school year, we would like to ask your child’s teacher about the amount of progress your child has made. Any information we would gather would be protected and your child would never be identified. The information provided would be combined with information from others and reported as a group. Allowing your child to take part in this study in the way just described will put your child at no more risk than he or she would experience during any normal day. Although your child may not benefit directly by being part of the study, it is possible that because of what we learn, the program may improve to better meet his or her needs or the needs of other students. Neither you nor your child will receive any money or other reward for taking part in this study. Allowing your child to be part of the study is completely voluntary. If you decide not to allow your child to be part of it, there will be no penalties or loss of benefits to you or your child.

To allow us to collect this information from your child’s teacher there is no action you need to take. Thank you!

If you do NOT want your child to be part of the study, just fill in the information below and return this form to the afterschool program coordinator.
Student Name*

First NameLast Name
Type a question

Do not include my child in the evaluation studyI give my permission for my child to be included in the evaluation study
Signature

Clear
Date

MonthDayYear
Date
Program Name
For more information about the education program we are studying, you may contact Sherry Swint at sherry.swint@k12.wv.us. If you have questions about this evaluation study, you may contact Jonathan Rollins at Jonathan.rollins@k12.wv.us . This study has been reviewed and approved by the West Virginia Department of Education Institutional Review Board (IRB-WVDE-041

Parents: Keep a copy of this form for your records.
Should be Empty:

EXCEL Registration

Bus Announcement

Terms & Policies

Medical Release