Bay Area Community Resources: Caliber Academy Registration Packet 1

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1 Dear Parents/ Caregivers, The After School Program at Caliber Academy, will begin on the first day of school, August 23, 2016 and run until the end of the school year. The program will serve Kindergarten- 8 th grade and operate on school days until 6:00pm. We want to invite you to enroll for the school year. The After School Program offers academic support, homework help, and enrichment. This program will provide a daily snack and a safe nurturing environment for your child. Filling out this application does not guarantee initial enrollment in the After School Program. Once accepted you will receive a phone call to confirm that your student is in the program or on the waitlist by 8/19/16. If you turn in an application after this date, you will receive a phone call no later than a week after you turn in your application. If your student is not initially accepted in the After School Program he or she will be placed on the waiting list. Students in Kindergarten- 2 nd grade will be in the ASES funded program and therefore must adhere to the grant requirements below: 1. Attend five (5) days a week 2. Stay until 5:45pm every school day. Students in 3 rd - 8 th grade do not need to adhere to the ASES grant requirements, although they will need to adhere to the attendance policy and early release process of the after school program. Please fill out the entire application in order to be considered. Applications should be returned during the enrollment time slots below. We will begin enrollment on August 8th from 12:00pm-4:30pm as follows: Kindergarten-2nd grade: 12:00pm-2:00pm 3rd-8th grade: 2:30pm-4:30pm This year, there will also be program fees. Please see below: # of Children in Program Flat Fee amount for year First Installment- Due Second Installmentat Parent Orientation Due Feb 1 st 1 $270 $135 $135 2 $405 $202.5 $ $540 $270 $270 Thank you, Kim Lewis ASP Coordinator E: klewis@bacr.org C: (510) Bay Area Community Resources: Caliber Academy Registration Packet 1

2 Caliber Academy After School Program Registration Packet Student Information Last Name First Name Grade ( ) If you are enrolling more than one student please add other children below: Last Name First Name Grade ( ) Last Name First Name Grade ( ) Last Name First Name Grade ( ) Parent/Guardian #1 Information Last Name First Name Best Contact program hours Address City Zip code Home Phone Work Phone Cell Phone Address

3 Parent/Guardian #2 Information Last Name First Name Best Contact program hours Address City Zip code Home Phone Work Phone Cell Phone Address Authorized Persons Please fill out this section of persons who will be allowed to pick up your child(ren) from the AS program or who may be contact in case of an emergency. 1. Name Phone Relationship 2. Name Phone Relationship 3. Name Phone Relationship 4. Name Phone Relationship 5. Name Phone Relationship Bay Area Community Resources: Caliber Academy Registration Packet 3

4 Student Health Information Last Name First Name Birthdate Students known allergies or conditions List any medications student is currently taking Last Name First Name Birthdate Students known allergies or conditions List any medications student is currently taking Last Name First Name Birthdate Students known allergies or conditions List any medications student is currently taking Health Care Provider Policy/ Insurance # Physicians Name Physicians Phone Number

5 Release of Liability, Waiver, and Indemnification Agreement I, the undersigned herby authorize my child/children, to participate in Bay Area Community Resources Caliber Academy After School Program. In consideration for permission to participate, I do herby, for myself, my heirs and assigns, on behalf of my child/ward, and his or her heirs and assigns, release and agree to indemnify and hold harmless Bay Area Community Resources and Caliber Academy, their officers, staff, agents, employees and volunteers from any and all liability, loss, claim, demand, action or cause of action which arise or be occasioned in any way by such participation. Parent/Guardian Signature Date PERMISSION TO ACCESS STUDENT DATA, EVALUATE PROGRAMS AND TRACK STUDENT PROGRESS I/we give permission for the Program Staff to review my/our child s school data (test scores, report cards, Individual Education Plans, and other performance indices), for the purposes of providing targeted academic instruction and assessing the academic effectiveness of the Program. I/we also give permission for Program staff to monitor progress and to give my/our child evaluation surveys to determining program effectiveness. X Signature of Legal Parent or Guardian Today s Date Bay Area Community Resources: Caliber Academy Registration Packet 5

6 PHOTO/VIDEO RELEASE During your child s attendance in the Program, s/he may be participating in an activity that is being photographed or videotaped; these photographs/video recordings may be used for promotional purposes. My child: may may not be photographed/videotaped by the program for promotional purposes. I authorize Bay Area Community Resources, or any third party they have approved to photograph or videotape my child during program activities and to edit or use any photographs or recordings at the sole discretion of Caliber Academy or Bay Area Community Resources. I understand that I and my child shall have no legal right or interest arising from the recording, including economic interest. I also agree to release and hold harmless Caliber Academy, Bay Area Community Resources, and any third party they have approved from and against all claims, demands, damages, and liabilities arising out of or use of the recording. X Signature of Legal Parent or Guardian Today s Date

7 Payment Policy Bay Area Community Resources (BACR) is the agency in which the Caliber Academy After School program is under operation. The program is a partial fee based program and families are expected to pay their participation fees on the payment due date.. Please see the attached payment worksheet for your fee based on the number of students enrolling into the program. Please Initial next to each policy to verify that you understand the terms and conditions of payment to Bay Area Community Resources. First installment is due at the Parent Orientation and the second installment is due on February 1 st Fees must be paid in form of check or money order. Fees are due for every student that is enrolled into the program. There will be a limited amount of scholarships that will be awarded. Payments will not be prorated for any reasons. First month s payment are due at time of parent orientation and must be paid before enrollment can begin. Students who are picked up after 6:05pm may be charged a late fee of $1.00 for every minute they are picked up late after the 5 minute grace period of 6:05pm. Late pick up fees will need to be paid by next program day. Bay Area Community Resources: Caliber Academy Registration Packet 7

8 Payment Policy (cont) Below is an example of a payment made to Bay Area Community Resources. Please follow the guidelines below when making a payment to BACR. Bay Area Community Resources or BACR Student s Full Name Signature Please ensure that all payments made are written legibly and in black or blue ink only. All payments need to include child s full name (no nicknames). Please make payment payable to: Bay Area Community Resources or BACR. Receipts will be given out either upon payment or within 48 hours of payment via or in person.

9 Bay Area Community Resources Payment Worksheet Yearly Fee: # of Children in Program Flat Fee amount What it breaks down to per day 1 $270 $1.50 a day x 180 days 2 $405 $2.25 a day x 180 days 3 $540 $3.00 a day x 180 days 4 $675 $3.75 a day x 180 days These fees can be paid in full at the time of registration or in two installments. One at the parent orientation on 8/16/16 or 8/18/16 and the following on February 1 st All payments are either money order or cash. Bay Area Community Resources: Caliber Academy Registration Packet 9

10 Estimados padres / cuidadores, El programa después de clases en la Academia Calibre, empezará el primer día de clases El 23 de Agosto del 2016 y durará hasta el final del año escolar. El programa servirá grados Kinder-8 y operar en días de escuela hasta las 6:00 pm. Queremos invitarlos a inscribirse para el año escolar El programa después de clases ofrece apoyo académico, ayuda con las tareas, y classes de enriquecimiento. Este programa proveerá un bocadillo diario y un ambiente seguro para su hijo. Llenar esta solicitud no garantiza la inscripción inicial en el programa después de clases. Una vez aceptado, recibirá una llamada telefónica para confirmar que su hijo está en el programa o en la lista de espera. Recibira la llamada antes o el dia 08/19/16. Si entrega una aplicación después de esta fecha, usted recibirá una llamada telefónica a más tardar una semana después de que entregue su solicitud. Si el estudiante no es aceptado en el programa después de clases él o ella será colocado en lista de espera. Los estudiantes de Kinder a 2º grado estarán en el programa financiado por ASES y por lo tanto deben cumplir con los requisitos de la subvención siguientes: 1. Asistir a cinco (5) días a la semana 2. Asistir hasta las 5:45 pm todos los días escolares. Los estudiantes de 3r a 8º no necesitan cumplir con los requisitos de la subvención ASES, aunque tendrán que cumplir con la política de asistencia y el proceso de liberación anticipada del programa después de clases. Por favor llene toda la aplicación con el fin de ser considerados. Las solicitudes deben ser devueltos durante los intervalos de tiempo de la inscripción de abajo. Vamos a comenzar la inscripción el 8 de Agosto de 12:00-4:30 pm de la siguiente manera: Kinder a 2º grado: 12:00 pm -2:00pm 3r a 8 grado: 2:30pm -4:30pm Este año, también habrá honorarios del programa. Por favor ver más abajo: # De Niños en el Programa cantidad de cuota fija para el año En primer lugar Installment- Debido a la Orientación para Padres 1 $270 $135 $135 2 $405 $202.5 $ $540 $270 $270 Gracias, Kim Lewis Coordinador ASP E: klewis@bacr.org C: (510) En segundo lugar Installment- Debido Feb 1 ª

11 Academia Calibre Programa Después de Clases Paquete de Registro Student Information Apellido Nombre Grado ( ) Si se está inscribiendo más de un estudiante por favor, añadir otros niños a continuación: Apellido Nombre Grado ( ) Apellido Nombre Grado ( ) Apellido Nombre Grado ( ) Información de 1 Padre/ Tutor Apellido Nombre Mejor Numero de contacto durante horas de programa Direcion Ciudad Codigo Postal Telefono de casa Telefono de trabajo Telefono de Cellular Correo Electronico Bay Area Community Resources: Caliber Academy Registration Packet 11

12 Información de 2 Padre/ Tutor Apellido Nombre Mejor Numero de contacto durante horas de programa Direcion Ciudad Codigo Postal Telefono de casa Telefono de trabajo Telefono de Cellular Correo Electronico Las personas autorizadas Por favor complete esta sección de las personas que tienen autorización para recoger a su hijo (s) del programa de AS o que pueden ser de contacto en caso de una emergencia. 1. Nombre Numero Relacion 2. Nombre Numero Relacion 3. Nombre Numero Relacion 4. Nombre Numero Relacion 5. Nombre Numero Relacion

13 Student Health Information Apellido Nombre Birthdate Alergias o Condicioes medicos del estudiantes Medicamentos Apellido Nombre Birthdate Alergias o Condicioes medicos del estudiantes Medicamentos Apellido Nombre Birthdate Alergias o Condicioes medicos del estudiantes Medicamentos proveedor de atención médica # de polisa/ seguro Nombre de Doctor Numero De Doctor Bay Area Community Resources: Caliber Academy Registration Packet 13

14 Exención de Responsabilidad, Renuncia y Acuerdo de indemnización Yo, el firmante autorizo a mi hijo / hijos, para participar en Bay Area Recursos de la Comunidad Calibre Academia programa después de clases. En consideración de permiso para participar, lo hago herby, por mí mismo, mis herederos y cesionarios, en nombre de mi hijo / pupilo, y sus herederos y cesionarios, de liberación y de acuerdo en indemnizar y mantener indemne a Bay Area Recursos de la Comunidad y Caliber Academy, sus oficiales, empleados, agentes, empleados y voluntarios de cualquier y toda responsabilidad, pérdida, reclamo, demanda, acción o causa de acción que surja o se ocasionó en modo alguno por dicha participación. Firma del padre legal o tutor Fecha Permiso para acceder a datos de los estudiantes, evaluar programas y registrar el avance ESTUDIANTE Yo / nosotros doy permiso para que el personal del programa para revisar los datos de mi / nuestro niño en edad escolar (resultados de exámenes, calificaciones, Planes Individuales de Educación, y de otros índices de rendimiento), a efectos de proporcionar la instrucción académica específica y la evaluación de la eficacia académica del Programa. Yo / Nosotros también dan permiso para que el personal del programa para monitorear el progreso y para dar / nuestras encuestas de evaluación de mis hijos para determinar la efectividad del programa. X Firma del padre legal o tutor Fecha

15 FOTO / LIBERACIÓN DE VIDEO Durante asistencia de su hijo en el Programa, s / él puede estar participando en una actividad que está siendo fotografiado o grabado en vídeo; estas fotografías / grabaciones de vídeo pueden ser utilizados con fines promocionales. Mi hijo: Si, Doy Permiso No, Doy Permiso ser fotografiado / grabado en vídeo por el programa para fines promocionales. Autorizo a Bay Area Recursos de la comunidad, o de terceros que han autorizado a la fotografía o video de mi hijo durante las actividades del programa y de editar o uso de fotografías o grabaciones a la sola discreción de la Academia calibre o área de la Bahía recursos de la comunidad. Entiendo que tengo a mi hijo y no tendrá ningún derecho legal o intereses derivados de la grabación, incluyendo el interés económico. También estoy de acuerdo en liberar Academia Calibre inofensiva, Bay Area Recursos de la Comunidad y terceros que hayan autorizado, de y contra todas las reclamaciones, demandas, daños y responsabilidades derivadas de o el uso de la grabación. X Firma del padre legal o tutor Fecha de Hoy Bay Area Community Resources: Caliber Academy Registration Packet 15

16 Política de pago Recursos de la comunidad de la zona de la Bahía (BACR) es la organisacion en el que el programa Calibre Academia después de la Escuela está en funcionamiento. El programa es un programa basado en una cuota parcial y se espera que las familias pagen sus cuotas de participación en la fecha de vencimiento del pago. Por favor, vea la hoja de pago adjunta para su tarifa basada en el número de estudiantes que se inscriban en el programa. Por favor, sus iniciales al lado de cada política para verificar que usted entiende los términos y condiciones de pago de Bay Area Recursos de la comunidad. Al primer tramo se debe el dia de la orientación de los padres y el segundo plazo vence el 1 de Febrero de Los honorarios deben ser pagados en forma de cheque o giro postal. Los honorarios son de vencimiento para cada estudiante que está inscrito en el programa. Habrá una cantidad limitada de becas que se otorgarán. Los pagos no serán prorrateados por cualquier motivo. Pago del primer mes se debe en el momento de la orientación de los padres y debe ser pagado antes de la inscripción puede comenzar. Los estudiantes que son recogidos después de 6:05 pueden ser acusados de un cargo de $ 1.00 por cada minuto que son recogidos tarde después del período de gracia de 5 minutos de 6:05. Finales tendrán que ser pagados por día siguiente programa de recoger los honorarios.

17 Política de pago (continuación) A continuación se muestra un ejemplo de un pago realizado a Bay Area Recursos de la comunidad. Por favor, siga las siguientes pautas al hacer un pago a BACR. Bay Area Community Resources o BACR Nombre De Estudiante Signature Asegúrese de que todos los pagos realizados se escriben de forma legible y sólo tinta de color negro o azul. Todos los pagos deben incluir el nombre completo del niño (no apodos). Por favor hacer el pago a nombre de: Bay Area Recursos de la Comunidad o BACR. Los recibos serán entregados ya sea mediante el pago o dentro de 48 horas de pago por correo electrónico o en persona. Bay Area Community Resources: Caliber Academy Registration Packet 17

18 Hoja de Pago Área de la Bahía de la Comunidad de Recursos Cuota Anual: # of Children in Program Flat Fee amount What it breaks down to per day 1 $270 $1.50 a day x 180 days 2 $405 $2.25 a day x 180 days 3 $540 $3.00 a day x 180 days 4 $675 $3.75 a day x 180 days Estas cuotas se pueden pagar en su totalidad al momento de la inscripción o en dos plazos. Uno en la orientación de los padres en 8/16/16 o 8/18/16 o el siguiente, y el 1 de Febrero de Todos los pagos son o giro postal o efectivo.

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