OHMS Coda Registration Fall 2024

OHMS Coda Registration: Fall 2024
The following registration form is for 6th-8th grade students for Coda Unplugged on Monday, Coda Quest on Tuesday, and Coda Inspire on Wednesday at Oak Hill Middle School.

WHEN: September 9, 2024 - December 11, 2024 from 2:30 PM - 5:00 PM.

WHERE: OHMS

COST: FREE!!!!

GRADES: 6TH-8TH

Free meal/snacks provided.

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

*Free bus rides are available for all OHMS students who live within the OHMS school district.

*Students from other schools (homeschool, private, FPK8, etc.) are welcome to attend Coda at OHMS on any day, but unfortunately we cannot provide busing for these students.

Please email Coda Mountain Academy at info@codamountain.com or call at (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 (Required for Grant Purposes)*
Student Gender (Required for Grant Purposes)*
Student Ethnicity (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.
Text Consent 1: Do you consent to receive text messages at this phone number? We may send a text in events of cancellations, emergencies, and announcements. If you don't want to receive text messages from us, you will only receive this information via email.*

YesNo
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.
Text Consent 2: Do you consent to receive text messages at this phone number? We may send a text in events of cancellations, emergencies, and announcements. If you don't want to receive text messages from us, you will only receive this information via email.

YesNo
Home Address*

Street Address

Mailing Address

CityState / Province

Postal / Zip Code
Is your yearly income $35,000 or below? (Required for Grant Purposes: The program is free no matter your income.)*

YesNo

Terms & Policies
Loaned Instrument Policy: Our musical 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 due to the requirements of our grants, regular attendance is very important.*

I understand that regular attendance is expected and any student missing more than three weeks without a valid reason and a written parent or doctor excuse may be dismissed 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
Free busing will be provided to take OHMS students home after programming ends. Unfortunately, busing home is not available for FPK8, homeschool, or private school students.

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.
Permission to ride the bus from OHMS to Pinheads*

I give permission for my child to ride the bus from OHMS to Pinheads on MondaysI will transport my child from OHMS to Pinheads on Mondays
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 partially 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

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 21 st 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 before/after school program staff member named below or Sherry Swint, 21st CCLC Coordinator, at the West Virginia Department of Education (304-558-7805 Ext:3138).
Child's Name (please print)*
Signature*

Clear
Date*

MonthDayYear
Date
21st CCLC Staff Member*
Program Name*
Site Name*
Click "Submit" to turn in the registration form.

Once you have submitted this form, your child is enrolled in Coda for the days you selected. If you provided us with a valid email address in this registration form, you will receive an email confirmation from jotform informing you that we have received your form. Please remind your student to stay afterschool for Coda on the days you have registered them for. Programs will start the week of September 9th.
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OHMS Coda Registration: Fall 2024

Programs

Terms & Policies

Bus Announcement

Medical Release

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

Click "Submit" to turn in the registration form.