FPK8 Coda 3rd-4th Grade Spring 2025

FPK8 Coda 3rd-4th Grade: Spring 2025
This registration form is for 3rd-4th grade students for Coda programs at Fayetteville PK-8 for the Spring 2025 Semester. Once this form has been submitted, the student is enrolled and can stay afterschool for the days they have registered for on this form. Students in 3rd and 4th grade can take Agriculture/Horticulture on Monday, Music/Art classes on Tuesday, and Robotics/STEAM classes on Thursday. Active SWV will have a Hike/Disc Golf club on Wednesdays from 3:30-5:00 PM (students must register separately with Active SWV at their website: https://activeswv.org/21cclc/).

WHEN: February 3 - May 15, 2024, 3:30 PM-5:30 PM

WHERE: FPK8

COST: FREE!!!!

GRADES: 3RD-4TH

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 public school students who live within the FPK8 school district.

*Other public, private and homeschool students are welcome to attend Coda at FPK8, but unfortunately we cannot provide busing for these students.

Please email Coda Mountain Academy at 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 (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 send texts in the event of cancellations, emergencies, and announcements. If you don't choose to receive text messages from us, you may miss important information.*

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 send texts in the event of cancellations, emergencies, and announcements. If you don't choose to receive text messages from us, you may miss important information.

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 consistent attendance is expected and that any student who is absent more than three times 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 FPK8 students home after programming ends on Monday (Coda Grow), Tuesday (Coda Inspire), Wednesday (Active SWV Hike/Disc Golf club), and Thursday (Coda Inspire). Unfortunately, Fayette County Schools is currently unable to transport students from other public, private schools, or homeschool students.

Buses leave the school around 5:30 pm on Monday, Tuesday, and Thursday, and around 5:00 pm on Wednesday. If a child is 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. STUDENTS WHO REGISTER AS BUS RIDERS, MUST HAVE A SIGNED NOTE FROM A PARENT/GUARDIAN WHEN THEY NEED TO GO HOME ANOTHER WAY (i.e. as a walker or car rider).
Bus Info*

My child will be riding home on the busMy child will NOT be riding home on the bus
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- NOT A PARENT/GUARDIAN (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, and agree to hold Coda Mountain Academy free and harmless of claims in the event of injury, accident, illness, or other emergency. 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

Consent Forms
CONSENT FORM 1: 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
CONSENT FORM 2: This is only for students in 3rd-5th Grade. 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)

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

CONSENT FORM 1
(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 "Next" to continue the application.

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

Parent / Guardian Denial of Consent

CONSENT FORM 2

(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)
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.

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.
Child's Name (Please print)*
Do not include my child 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.
Click "Submit" to register your child for Coda.

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 starting the week of February 3rd.
Should be Empty:

FPK8 Coda 3rd-4th Grade: Spring 2025

Programs

Terms & Policies

Bus Announcement

Medical Release

Consent Forms

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

Click "Next" to continue the application.

Click "Submit" to register your child for Coda.