DYMON H.G. Hill Middle School Enrollment Form 2024-25

Fall Semester: September 3, 2024 to December 13, 2024 Spring Semester: January 8, 2025 to May 9, 2025

Who we are:

DYMON is a holistic program that creates fun and engaging ways to support student's academics, youth development, and leadership skills. We will intentionally cultivate experiences where youth build self-confidence, healthy relationships, and know their true value and purpose. Our focus is youth-led and youth-supported initiatives.

Program:
o DYMON- H.G.Hill Middle After School Program 3:55 pm-6:00 pm (females only)

Location: H.G. Hill Middle School

Transportation: Transportation is provided to students that live in H.G. Hill Middle's school zone. Transportation is limited and assigned on a first-come, first serve basis.

STUDENT ID

Youth's Name*

First NameLast Name

Welcome call made?

Added to Remind?

YesNo

Transportation request completed?

YesNo

Name you like to be called

Address*

Street Address

Street Address Line 2

Zip code

County*

School*

Youth’s cell phone #

Please enter a valid phone number.

Youth’s email address

example@example.com

Youth’s date of birth*

Date

Gender*

Female

Grade*

678

Ethnicity (Click all that apply)*

Youth’s T-Shirt Size*

Does your child have an IEP (Individual Education Plan)?*

YesNoPrefer not to answer

Is your child an ELL student (English Language Learner)?*

YesNoPrefer not to say

What is the name of your child's English/ Language Arts Teacher?

What is the name of your child's Math Teacher?

Custodial Parent/ Guardian *

First NameLast Name

Relationship to youth*

Custodial Parent Phone Contact*

Custodial Parent Email address*

example@example.com

Alternative Contact for Emergencies

First NameLast Name

Relationship to youth

Alternative Contact Phone #

Does your youth take medication?*

YesNo

Does your youth have any physical restrictions?*

YesNo

Does your youth have any allergies or food restrictions?*

YesNo

Does your youth have any illnesses or conditions that we need to be aware of?*

YesNo

If you checked "yes" on any of the above, please give us details so we can care for your child properly:*

Preferred hospital if your youth needs medical care*

Primary Doctor

Doctor Phone

Health Insurance Company Name

Policy

My youth rides the school bus in the morning*

YesNo

I want my youth to ride the school bus home from the NAZA-funded afterschool program.*

YesNo

Will your child need to be dropped off at an address different from the one above?*

YesNo

Address

Street Address

Street Address Line 2

Postal / Zip Code

My student has permission to ride a Metropolitan Nashville Public Schools School Bus from school to my student's regular bus stop to participate in extended school day activities. I understand that my student may be en-route on the school bus in excess of one (1) hour. I understand that transportation services may not be provided for my student if we reside in a parent responsibility zone. I further understand that services will not be provided on early release school days, snow days, or any other day school is not in session. My student and I understand that this service is a privilege, and further understand that bus service will be discontinued should the student misbehave or violate school system's safety rules. My student and have read the attached Bus Rider Rules and agree to abide by them.*

I AgreeI Disagree

I or someone else will pick my child up from programming each day?*

YesNo

Name of person allowed to pick your child up (if different from the custodial parent or emergency contact)

Relationship to youth

Phone

The Tennessee Department of Education partners with the University of Tennessee Social Work Office of Research and Public Service to evaluate extended learning programs funded by (Nita M. Lowery 21 st Century Community Learning Centers /Lottery for Education Afterschool Programs) grants. Part of that evaluation includes a survey for students in grades 3-12. The survey is anonymous: your child will not be asked to provide their name when they complete the survey. The survey asks about your child's experience of the extended learning program and their response will support continued high-quality programming. The survey can be reviewed at TN-ELAP.org/User News. Please indicate below if you consent to have your child participate in the survey. *

Student Record Release Permission

Nashville After Zone Alliance (NAZA) partner agency, DYMON in the Rough, receives information from Metro Nashville Public Schools (MNPS) about the students that are enrolled in NAZA-funded or affiliated programs. The programs utilize personally identifiable information (PII) from students' school records to plan and provide high-quality after-school programming for your student. Information that is deemed as part of the student's school record is listed below:

School ID
School name
Student number
Last name
First name
Middle name
Preferred name
Birthdate
Gender
Grade level
IEP Status (Presence of an IEP, and dates that indicate if a new IEP is due) Note: MNPS will not share any additional information about your child's IEP. The parent/guardian is the only person(s) allowed to disclose any additional information about the IEP.
Daily Attendance record
Number of suspensions (in and out of school)
Academic achievement data, such as State summative assessment/TCAP(if administered) Interim benchmark assessment/MAP, College and career readiness assessments, WIDA ACCESS for English Learners, Class grades
Access to devices (computer, tablet) and internet at home

The information will be treated as confidential in agreement with the Family Educational Rights and Privacy Act (FERPA), will not be released to any other parties that are neither associated nor affiliated with NAZA, and will be used for the sole purposes to continue providing high quality after school programming to your child. NAZA personnel and DYMON in the Rough will be properly trained to protect your student's Personally Identifiable Information (PII Any PII that has been collected and maintained by Backfield in Motion will be permanently destroyed at the end of the academic year.

I give my permission to the Nashville After Zone Alliance and DYMON in the Rough, unless otherwise noted in the space below:

a. To have my child participate in NAZA-funded programs and activities at my child's school as well as other off-site locations throughout the NAZA system, as specified in this enrollment form, knowing that this might include special activities, such as off-site events, end-of-year celebrations, homework/academic help, and field trips, and realizing that some of these may take place outside of regular program hours.

b. With the medical information provided in the program application in mind, engage in all activities except as noted.

c. To secure proper medical treatment for my child in the event of an emergency. If I or my emergency contact cannot be reached, I give permission for a physician to order routine tests and treatment for the health of my child. I give permission to a physician to secure treatment and/or hospitalize my child; after all emergency, contact attempts have been made.

d. To provide assistance in accessing devices and internet services when presented as a barrier for my child to participate in afterschool and summer programs.

e. To use in media releases to benefit NAZA and its funded providers, photographs, creative work, quotes, videos, or other media which may include my child.

I, the undersigned, understand, acknowledge, and agree:

That I have read and understand the information provided in the Parent Consent Form.
That I will update any information I provided about my student in a timely fashion.
That DYMON will request my child's records that may contain personal information (share demographics, grades, assessment, attendance, behavior/suspensions, IEPs, and information about access to technology and the internet at home) for the sole purpose of helping my child succeed in school and beyond.
I, therefore, waive, with respect to these disclosures, any duty of confidentiality arising from Federal or State requirements. That participation in NAZA-funded programs and providing information about my child may involve certain risks. I assume all of these risks.
That DYMON will make themselves available to children, parents, and school staff and any concerns they might have.
That DYMON will protect the safety, interests, and rights of all individuals in the program. Therefore, each program will provide a parent/youth handbook or other program-specific information, including behavior policies and grievance procedures.
That my child may be asked to complete surveys regarding the program for evaluation purposes.
That I will not seek to hold NAZA or its funded providers responsible for any losses or damages whatsoever which I or my child may incur in connection with NAZA or its funded providers.
That all program staff are employed by DYMON, who are responsible for the operations of the program and supervision of their personnel. NAZA takes no responsibility for these operations or supervision.
I, the parent or legal guardian, give consent for Metro Nashville Public Schools to share my child's information, as described above, with NAZA staff and its funded and affiliated partners for the purpose of planning and providing high-quality afterschool programming to my child. I fully release and discharge MNPS and its employees from any and all liabilities arising out of or in connection with the above-described data sharing relative to NAZA and NAZA partners. I reserve the right to withdraw my consent at any time by submitting a written notice of withdrawal of consent to NAZA or its partner.

Date*

Date

Signature Custodial ParentGuardian*

DYMON H.G. Hill Middle Enrollment Form 2024-2025

A. Youth Information

B. Family & Emergency Information

C. Medical Information

Transportation

Unified Parent Consent Form