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ASPIRE Reg. 2021-22
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ASPIRE Reg. 2021-22
ASPIRE Registration Form 2021-22
PROGRAM INFORMATION
Program Update
At this moment in time, we do not have any information as to how our partner schools' regular school day or school calendar/schedule will be structured for the return to school in Fall 2021, however we are still proceeding with our ASPIRE program registration process as usual.
Program Guidelines
Students enrolled in the ASPIRE after school program must attend the program EVERY DAY they attend school, Monday - Friday, for the entire duration of the program, from the end of the school day until 6:00 PM. If the student is accepted into the program, their parent/guardian is required to attend a Program Orientation for Parents in Fall 2021 in order for their child to be eligible to continue attending the ASPIRE program during the 2021-22 school year. Failure to attend this Orientation may lead to the student being removed from the program and added to the Student Enrollment Wait List. For the safety of all of our program participants and staff, the program will be abiding by all the rules and regulations set for public schools by the Los Angeles County Department of Public Health, which may include limited program participation, social distancing and wearing face masks. Full details regarding these requirements will be presented at the mandatory Parent/Guardian Orientation prior to the start of the school year.
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
What school will your son/daughter attend NEXT school year?
*
Please Select School
Cherrylee
Cleminson
Columbia
Cortada
Durfee
Emerson
Gidley
LeGore
New Lexington
Potrero
Rio Hondo
Rio Vista
Shirpser
Wilkerson
Wright
Verification: What school will your son/daughter attend during the 2021-22 school year?
*
Have you already enrolled your son/daughter for 2021-22 school year at the school you selected above?
*
Yes
No
ID Number (Student IDN)
*
This is the number located on your child's school ID card.
Student Name
*
First
Middle
Last
Student Gender
*
Please select one
Male
Female
Other
Prefer not to say
Student Grade in Fall 2020
*
This is the grade your child WAS enrolled in for Fall 2020.
Please select one
TK
K
1
2
3
4
5
6
7
8
Student Grade in Fall 2021
*
This is the grade your child will be GOING INTO for Fall 2021.
Please select one
TK
K
1
2
3
4
5
6
7
8
Student Date of Birth
*
(mm/dd/yyyy)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Student Age
*
Student Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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 the first day of school in August 2021.
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
STUDENT HEALTH HISTORY & INFORMATION
If your son/daughter is required to be administered medication during program hours, an "Authorization to Medicate" form must be completed and submitted to LEARN. The form requires the physician's signature. If you list any medications here, you will be emailed a printable copy of the form. A paper copy of this form can also be obtained from the Site Coordinator. Please follow the completion instructions on the form. If not applicable type N/A.
Medications
*
Medical Conditions
*
Allergies
*
Primary Care Physician's Name
*
Primary Care Physician's Phone Number
*
### - ### - ####
Health Insurance or Health Plan Provider
*
Health Policy/Plan Number or Member ID
*
INTEREST IN BEFORE SCHOOL ASPIRE PROGRAM
If your child is attending, Columbia, Durfee, Gidley, LeGore, Rio Vista, or Wright, please let us know if you are interested in receiving a registration form for our Before School ASPIRE Program. Please note that if your student's school was not listed above, this question does not apply to you as it is not currently being offered at that site.
Please send me a Before School ASPIRE registration from:
Please select one
YES
NO
AUTHORIZATION FOR RELEASE OF STUDENT
Students in Grades TK - 5 will not be released to walk home at program-end and must be picked up by an Authorized Adult listed on this form. Students in Grades 6 – 8 may be released to walk home at program-end if a parent/guardian authorizes LEARN staff to do so. Such authorization must be provided on this form.
Initials of Parent/Guardian
My son/daughter is in Grade 6, 7 or 8 and therefore eligible to be released to walk home alone with my written authorization. My initials below authorize LEARN personnel to release my son/daughter when the program ends so he/she can walk home alone. If this field is left blank and/or my initials are not listed below, I understand that my son/daughter will NOT be released to walk home alone at program-end.
AUTHORIZED ADULTS
LEARN will include the names of both parents/guardians listed on this Registration Form as Authorized Adults in the student information system. LEARN will only remove a parent from the student information system with a legal document that instructs that action, such as valid court documentation that restricts a birth parent’s access to a child. The parent or legal guardian of a student must authorize any other adults they will permit to take physical custody of their child when picking them up from the program. Such authorization must be provided on this form. All authorized adults will be entered into the student information system as being approved by the parent/legal guardian. Only the parent/legal guardian may request changes to the list of authorized adults in the student information system. Authorized adults must produce valid, unexpired, photo identification to LEARN staff. Adults who are not able to produce valid identification will not be allowed to pick-up a student from the program, regardless of whether the adult’s name appears on this form or in the LEARN student information system as an emergency contact or authorized person. It is the sole responsibility of the parent/legal guardian to ensure that LEARN has the correct information for Emergency Contacts and Authorized Adults.
Emergency Contacts
Adults other than a parent/guardian must be 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
*
### - ### - ####
Adults Authorized to Pick-Up Student
Students in Grade TK – 5 will only be released to an authorized adult (over 18 years of age). The Authorized Adults must be listed below.
Authorized Person #1 - NAME
*
First
Last
Authorized Person #1 - PHONE NUMBER
*
### - ### - ####
Authorized Person #1 - RELATION TO STUDENT
*
Authorized Person #2 - NAME
*
First
Last
Authorized Person #2 - PHONE NUMBER
*
### - ### - ####
Authorized Person #2 - RELATION TO STUDENT
*
Authorized Person #3 - NAME
*
First
Last
Authorized Person #3 - PHONE NUMBER
*
### - ### - ####
Authorized Person #3 - RELATION TO STUDENT
*
Adults NOT Authorized to Pick-Up Student
Persons LEGALLY PROHIBITED from picking up my student (if applicable). You MUST provide your ASPIRE Site Coordinator with a copy of the legal document or court order, or fax it to LEARN at 562-945-0191.
NOT Authorized Person #1 - NAME
First
Last
NOT Authorized Person #1 - RELATION TO STUDENT
NOT Authorized Person #1 - REASON
NOT Authorized Person #2 - NAME
First
Last
NOT Authorized Person #2 - RELATION TO STUDENT
NOT Authorized Person #2 - REASON
PROGRAM DESCRIPTION & GUIDELINES
I understand that my child must attend the ASPIRE program EVERY DAY, Monday - Friday, for the entire duration of the program. I understand that my child may be dismissed from the program for excessive absences, tardiness or inappropriate behavior. I am also aware that the program ends at 6:00 PM and if my child is picked-up after that time, my child will receive a "Late Pick-Up Warning Form." If a student receives three (3) Late Pick-Up Warning Forms, he/she may be asked to leave the program.
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.
RELEASE OF INFORMATION
My signature below authorizes the exchange of information regarding my child’s academic progress between the ASPIRE staff and the staff at my child’s school.
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.
Email
This field is for validation purposes and should be left unchanged.
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2021 L.E.A.R.N.
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