Excel Fall 2024

EXCEL Registration: Fall 2024
The following registration form is for 3rd - 5th grade students at Fayetteville PK-8 on Mondays.

WHEN: Mondays, Sept. 16 - Dec. 9, 3:30 PM - 5:55 PM.

WHERE: The Coda Center; 2859 Maple Ave. Fayetteville, WV 25840 (Beside Fayetteville Christ Fellowship)

COST: FREE!!!!

BUSING: 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 info@codamountain.com or call (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.
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
Parent/Guardian 2

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
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: For greatest impact on the student, regular attendance is very important. Any student who misses more than three classes without a valid reason and a written parent or doctor excuse may be dismissed from the program.*

I understand the attendance policy and realize that my student is expected to attend regularly.
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

Click submit to register your child for Excel.

Once you have submitted this form, your child is enrolled in Coda Excel. 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 Excel on Mondays starting on September 16th.
Should be Empty:

EXCEL Registration: Fall 2024

Bus Announcement

Terms & Policies

Medical Release

Click submit to register your child for Excel.