• ROAR with the Y After School Program (ASP) and Tutoring Registration

    Please fill out the following information for YMCA ASP and Tutoring Registration.
  • See below for the ROAR ASP Handbook.

  • Student Information

  • Grade

  • Parent/Guardian Information

  • Relationship to Student:*

  • Approved Persons for Pickup

    Please do not include the primary adult listed on page three.
  • Relationship to Student:*

  • Emergency Contacts

    Please do not include the primary adult listed on page three.
  • Relationship to Student:*

  • LIST ANYONE NOT AUTHORIZED TO PICK UP YOUR CHILD

    Write N/A if not applicable.
  • Relationship to Student:*

  • General Permissions

    Sign your first/late name if you agree; leave blank if not.

  • ASP / Tutoring Pickup

    This year, the YMCA is jointly operating after school tutoring at Hixson Middle School. One hundred percent of our ASP tutors are certified educators employed at Hixson Middle School. While pickup from after school programming is required by 5:00pm, tutoring will finish by 4:00pm each day.
  • To the best of your ability, please indicate below if you plan to pick your student up before or after tutoring is over. If you are unsure, please select "Pickup May Vary."*

  • ASP Contact Information for Pick Up

    At this time, we are actively working towards setting up communication through Hixson Middle School's Parent Square. 

    Until then, please contact Austin Winter, YMCA Program Director, for student pick up. This is subject to change, and Austin will reach out with an official email to confirm official pick up communication changes once they are finalized. 

    Austin's cell: (615) 306-6376. 

  • Parent/Guardian Consent of Release of Information

    The YMCA, in partnership with HCDE and NNH, requests your permission for ongoing access to data about the student listed on this form. Data will be collected for the duration of your student’s participation in ROAR with the Y. The YMCA will be granted permission to view your student's data in PowerSchool.

  • The following specific data will be accessed by authorized staff:

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  • I understand that data access will be granted to the authorized YMCA staff. I understand that this data will be used for the development of my child’s after school education plan to provide academic support. Each authorized staff is responsible for maintaining confidentiality of accessed information. I understand that this data will be used to provide services for my students. Data may also be used, as approved, for the purpose of service tracking, grant reporting, and/or program evaluation. No identifying information about my student will be published.

    I understand that information on students/families will only be shared with consent. I understand that my consent is optional and I may choose to withdraw permission at any time by giving written revocation to my student's school and to the YMCA. I understand sharing my student’s data is not a requirement to participate in YMCA after school programming.

  • Family Needs Survey

    The survey provides information to help us understand and serve your needs. The YMCA, in partnership with NNH and HMS, does have access to provide some immediate basic needs and can also provide referrals to other organizations and plan future services. Data is kept in locked files and on secure servers. To better refer to services, we may share survey data with NNH and Hamilton County Department of Education (HCDE). No information is shared with outside parties or service providers without consent. By completing this survey, you are granting permission for use. Providing answers to the survey is optional.
  • Do you have access to the internet at home?*
  • Would you like more information about the following? Please select all that apply:*

  • Release Waver and Final Signature

    Please read the following information.

  • I hereby agree to be responsible for the conduct and actions of the student(s) registered on this form under my name and to release Hamilton County Schools, the YMCA of Metropolitan Chattanooga, and Northside Neighborhood House from any claims or demands that might occur while attending YMCA After School Programming. Furthermore, I agree to release HCS, NNH, the YMCA, and their staff, volunteers, and partner organizations from any liability that may arise from incidents or accidents involving the registered student(s) on HCDE premises to the extent allowed by law.

    I agree to support YMCA staff as needed (e.g., meeting for academic/behavioral challenges), which may include communication via phone, email, or in person meetings. I agree that my student will follow all rules and guidelines jointly set forth by HCDE and the YMCA and understand that both HCDE and the YMCA have the right to remove my student from the program if he/she does not adhere to rules and regulations.

    I understand that students will be dismissed to meet for after school programming when school is out of session each day. I understand that, upon arriving, my child will be received by YMCA staff, who will sign each child into the program. I understand that my child must arrive no later than 2:35pm, unless prior communication with YMCA staff or written documentation from school officials can be presented. I understand that parents, guardians, and others picking up my child must confirm their identify with a form of ID (e.g., driver's license) to YMCA staff prior to pick up. I understand that YMCA staff will not dismiss my child to persons who are not listed as an approved pickup person for my child's protection. To add a person as to the approved pickup list, I understand that I must request the addition at least one business day prior.  

    I understand that Roar with the Y meets Monday-Thursday, from 2:15pm to 5:00pm. I understand that my child must be picked up by 5:00pm each day. I understand that Roar with the Y is a free program, and I will not be charged a fee for my child to attend. I understand that Roar with the Y is made possible through fundraising, grants, and other charitable giving by the community to the J.A. Henry Community YMCA.

  • Austin Winter, Program Director

    J.A. Henry Community YMCA

    3500 Dodds Avenue, Suite 108

    E: awinter@ymcachattanooga.org

    P: (423) 805-3361

     

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