ASPIRE at Home

PROGRAM INFORMATION

While school campuses remain closed and distance learning continues, LEARN has moved the ASPIRE after school program online! Every school day between 2:00-6:00pm, registered students can log in to live virtual sessions with ASPIRE Youth Leaders for fun and engaging activities focused on health and fitness, social emotional learning, clubs, and more. See your school’s ASPIRE at Home Google Classroom for grade-specific Google Meets links.

Program Update

At this moment in time, we do not have any information as to when our partner schools will be resuming school or when we will be allowed to return to school sites, however we are still proceeding with our ASPIRE registration process as usual.

Program Guidelines

Students enrolled in ASPIRE at Home may choose to attend any virtual enrichment session at their school using their assigned EMCSD student email address. Participants are required to abide by EMCSD’s student code of conduct while interacting online. EMCSD provides all participants with a daily snack/supper that meets nutritional guidelines.

Equal Opportunity

LEARN is an Equal Opportunity Non-profit Organization committed to providing all employees and program participants an environment free of discrimination and harassment regardless of race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

STUDENT INFORMATION

At what school is your son/daughter enrolled?

ID Number (Student IDN)

This is the number located on your child's school ID card.

Student Name*

First Middle Last

Student Gender*

Student Grade in Fall 2020*

This is the grade your child will be GOING INTO for Fall 2020.

Student Date of Birth*

(mm/dd/yyyy)

Student Age*

Student Address*

Street Address Address Line 2 City State ZIP Code

Student Home Phone Number*

Student Mobile Phone Number

Student Email

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1 Name*

First Last

Parent/Guardian #1 Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #1 Home Phone Number*

### - ### - ####

Parent/Guardian #1 Mobile Phone Number*

Parent/Guardian #1 Email*

LEARN will send a confirmation receipt to this email address immediately after you have submitted this form. LEARN will also send the Notification of Acceptance or Waitlist to this email address by May 29, 2020.

Enter Email Confirm Email

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Address

(If different from Parent/Guardian #1)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian #2 Home Phone Number

### - ### - ####

Parent/Guardian #2 Mobile Phone Number

Parent/Guardian #2 Email

Emergency Contacts

Adults other than a parent/guardian must listed as emergency contacts below.

Emergency Contact #1 - NAME*

First Last

Emergency Contact #1 - HOME PHONE NUMBER*

### - ### - ####

Emergency Contact #1 - MOBILE PHONE NUMBER*

### - ### - ####

Emergency Contact #2 - NAME*

First Last

Emergency Contact #2 - HOME PHONE NUMBER*

### - ### - ####

Emergency Contact #2 - MOBILE PHONE NUMBER*

### - ### - ####

CONSENT TO USE OF VIDEO OR PHOTOGRAPHY

I understand that LEARN personnel may photograph and/or film my child during the program and I hereby consent to use of these photographs/video in LEARN's ASPIRE promotional material.

LIABILITY WAIVER

I hereby waive all claims against my child's school district, LEARN and its employees for injury, accident or illness occurring by reason of participation in ASPIRE. In case of an emergency, I authorize and licensed physician or hospital to render such medical aid as may be deemed necessary and/or desirable. Any cost/liability incurred for such treatment shall be my sole responsibility.

DIGITAL SIGNATURE OF PARENT OR LEGAL GUARDIAN

After clicking the SUBMIT button below, you will be automatically redirected to a page where you will review the information you entered and electronically sign the completed registration form. After signing, you will be able to save and print a copy of the signed form, in addition to being emailed a PDF copy of the form.

Phone

This field is for validation purposes and should be left unchanged.

ASPIRE at Home

ASPIRE at Home

PROGRAM INFORMATION

Program Update

Program Guidelines

Equal Opportunity

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

Emergency Contacts

CONSENT TO USE OF VIDEO OR PHOTOGRAPHY

LIABILITY WAIVER

DIGITAL SIGNATURE OF PARENT OR LEGAL GUARDIAN

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