2025-2026 Enrollment Form

STUDENT INFORMATION

The LAUSD requests your permission to reproduce through printed, audio, visual, or electronic means activities in which your pupil has participated in their program. Your authorization will enable us to use specially prepared materials to (1) train teacher, (2) increase public awareness and promote continuation and improvement of educational programs, and/or (3) highlight accomplishments of students and educational programs including but not limited to honor roll, school/District awards, and graduation/culmination, through the use of mass media, displays, brochures, website, social media, approved blogs, and related District publications.

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN 1 (REQUIRED)

PARENT/GUARDIAN 2

SIBLINGS IN THE ARC PROGRAM

For informational purposes only. A separate enrollment form is required for each student.

EMERGENCY CONTACTS/EMERGENCY RELEASE AUTHORIZATION

MESSAGE FOR ELEMENTARY/MIDDLE PARENTS: I understand that my child must be signed out of program every day by an authorized adult (18 years or older with picture ID). I authorize the following individuals to pick up my child, including in case of an emergency.

EMERGENCY CONTACT 1 (REQUIRED)

EMERGENCY CONTACT 2

EMERGENCY CONTACT 3

ANY PERSON TO WHOM THE STUDENT MAY NOT BE LEGALLY RELEASED?

BTB EARLY RELEASE FORM

FOR ELEMENTARY/MIDDLE SCHOOL STUDENTS

State Legislation governing after school programs for middle schools funded by After School Education and Safety Program and/or 21st Century Community Learning Centers mandates that such programs must operate from the close of school every school day until 6:00 p.m. Programs in schools that dismiss students after 3:00 p.m. must operate a minimum of 3 hours per day. The Los Angeles Unified School District requires a completed Early Release Policy form signed and dated by an authorized adult for any student released before 5:45 p.m. It is expected that middle school students attend 5 days a week and stay for the full duration of the program. In the event that a student is participating in other extracurricular activities during program hours, the parent/guardian or authorized person (18 years or older who is on the student’s emergency card) may pick up their child or may authorize the child to sign out of the program under the following conditions:

PARALLEL PROGRAM

Attending a parallel program (program in the school or community such as intervention programs, soccer, basketball, music lessons, religious education, etc.) as long as an agreement with the parent or guardian exists making this the child’s enrichment component.

TRANSPORTATION

During Standard Time, when the days are shorter and it gets dark early, a parent/guardian or authorized adult (18 years or older who is on the student’s emergency card) may pick up their child under the following condition:

Family does not have transportation, and they need to walk home before it gets dark.

Leave blank if this does not apply.

OTHER REASONS

In signing below, I request that my child be excused from the program at the specified time(s) and day(s) mentioned above. In addition to the reasons listed above, I request that my child be excused early on any dates where there are no transportation options or other family reasons that do not allow my child to remain for the full duration.

I understand neither the program provider nor the Los Angeles Unified School District is liable for incidents involving my child occurring after their departure from the program. I also understand services will be terminated if the program has a waiting list of students eligible to attend the program on a regular basis.  

LAUSD/BTB MEDIA WAIVER

The Los Angeles Unified School District requests your permission to reproduce through printed, audio, visual, or electronic means educational program activities in which your pupil has participated. Your authorization will enable us to use specially prepared materials to (1) train teachers, (2) increase public awareness and promote continuation and improvement of education programs, and/or (3) highlight accomplishments of students and educational programs including but not limited to honor roll, school/District awards, and graduation/culmination, through the use of mass media, displays, brochures, websites, social media, approved biogs, and related District publications.

a. I, as a parent or guardian, of the above named pupil fully authorize and grant the Los Angeles Unified School District and its authorized representatives, the right to print, photograph, record, and edit as desired, the biographical information, name, image, likeness, and/or voice of the above named pupil on audio, video, film, slide, or any other electronic and printed formats, currently developed, (known as "Recordings"), for the purposes stated or related to the above.

b. I understand and agree that use of such Recordings will be without any compensation to the pupil or the pupil's parent or guardian.

c. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the exclusive right, title, and interest, including copyright, in the Recordings.

d. I understand and agree that the Los Angeles Unified School District and/or its authorized representatives shall have the unlimited right to use the Recordings for any purposes stated or related to the above.

e. I hereby release and hold harmless the Los Angeles Unified School District and its authorized representatives from any and all actions, claims, damages, costs, or expenses, including attorney's fees, brought by the pupil and/or parent or guardian which relate to or arise out of any use of these Recordings as specified above.

PARTICIPATION AGREEMENT

ASES/21CCLC: Eligibility & Applications: Students are eligible to participate in Arc as long as they are enrolled at a partnering school during the regular school day. Enrollment in the Arc program is "first come, first serve," with priority given as follows: first priority goes to homeless and foster youth (EC § 8483[c][1][A] and § 8483.1[d][1][A]) as defined by McKinney-Vento (42 U.S.C. Sec. 11434a); second priority goes to students who attend daily (EC § 8483[c][B]); however, if the program is already at full capacity, enrolled students do not need to be removed to make room for high priority students (EC § 8483[c][3] The intention of the program is for pupils to attend the full length of the program daily, except as allowed by an early release policy (EC § 8483[a][2] Enrollment in the program is for the duration of one school year. Students are required to fill out a new application and re-enroll each academic year. Attendance: In accordance with California Education Code, students are expected to attend the program every day for the full range of hours offered (a minimum of 3 hours per day Students who do not attend regularly may be subject to disenrollment. Students must maintain an average attendance rate of at least 85% in order to avoid possible disenrollment.

ALL PROGRAMS: Participation Agreement: I agree to have my child participate in the Arc program. I understand that participation in Arc is a privilege, and that my child's failure to comply with the program's rules, regulations, and policies may result in disciplinary action, including but not limited to suspension or dismissal from the program. I understand that my child may risk bodily injury and or other loss, including damage to property, by virtue of participation. I knowingly and freely assume all such risk for myself and my child. I release and hold harmless Arc, its officers, agents, contractors, subcontractors, and employees with respect to any and all such injury and or loss, except when the injury or loss results from willful misconduct of Arc, its employees, or agents. My child's participation in this activity is purely voluntary and I elect to have my child participate, with acknowledgement of all known and unknown risks. I understand that Arc and the school district in which my child is enrolled, is NOT responsible for my child while they are not signed in to the program. I understand that the submission of this form does not guarantee my child placement in the Arc program.I further agree to reimburse Arc for all attorney's fees and costs should I bring legal action against Arc and lose. Information Release Agreement: I understand that the school and/or school district may share personally identifiable information with Arc to enable Arc to understand student needs, progress, and promote program participation. In addition, Arc may administer surveys and assessments to evaluate student progress. Medical Treatment Authorization: In the event my child suffers an illness or accident, I authorize Arc to seek medical help by contacting 911 emergency services or otherwise securing treatment at a medical facility. I acknowledge that Arc does not provide medical coverage for participants. Media/Product Release: I give my permission for my child to be filmed or photographed. Arc may use/publish work my child produces during arc activities. I understand that all film and photos are the sole property of Arc. Photos/videos/student work may be used in public displays, for marketing, or for printed materials published by and/or for Arc without compensation to the child or parent/guardian. I am the parent/guardian with legal custody of the above-named child, OR I am the above-named participant aged 18 years or older. The information on this application is accurate and complete to the best of my knowledge. I understand that this is the entire agreement between myself and Arc, its agents or employees, and it cannot be modified or changed in any way by the representatives or statements of any employees of Arc or by me. My signature below indicates that I have read this entire document and understand it completely and agree to be bound by its terms.

ENTIRE AGREEMENT: I understand that this is the entire Agreement between myself and Arc, its agents or employees, and that it cannot be modified or changed in any way by the representatives or statements of any employees of Arc or by me. My signature below indicates that I have read this entire document and understand it completely and agree to be bound by its terms.