VPK8 Coda 3rd-6th Grade Spring 2025

Valley Coda 3rd-6th Grade: Spring 2025
This registration form is for 3rd-6th grade students at Valley PK8 for Coda Inspire. Valley students in 3rd-6th grade can take music, art, or robotics classes on Mondays after school. Once this form has been submitted, the student is enrolled and can stay afterschool for the days they have registered for on this form.

WHEN: Feb. 17-May 12, 2025 from 2:30 PM - 5:00 PM.

WHERE: Valley PK8

COST: FREE!!!!

GRADES: 3rd-6th

BUSING: Free bus rides are available for all VPK8 students who live within the Valley school district. *Private and homeschool students are welcome to attend, but unfortunately we cannot provide busing for these students.

Free Meal/Snacks provided at the school.

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 (Required for Grant Purposes)*
Student Gender*
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
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's progress, regular attendance is very important.*

I understand that any student missing more than three classes 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 Valley PK8 students home after programming ends on Mondays. Unfortunately, busing is not available to private or homeschool students at this time.

Buses leave the school around 5:00 pm. 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. BUS STUDENTS MAY NOT WALK OR CAR RIDE WITHOUT WRITTEN PERMISSION FROM PARENT/GUARDIAN.
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- 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 Coda.

Once you have submitted this form, your child is enrolled in Coda for the semester. 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 Mondays starting with February 17th.
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Valley Coda 3rd-6th Grade: Spring 2025

Programs

Terms & Policies

Bus Announcement

Medical Release

Click "Submit" to register your child for Coda.