PREP Reg. 2021-22

PREP Registration Form 2021-22

  • 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 PREP program registration process as usual. 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 provided via email to parents/guardians and students 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

  • This is the grade the student will be GOING INTO for Fall 2021.
  • (mm/dd/yyyy)
  • PARENT/GUARDIAN INFORMATION

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  • (If different from Parent/Guardian #1)
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  • 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.
  • ### - ### - ####
  • Emergency Contacts

  • ### - ### - ####
  • ### - ### - ####
  • ### - ### - ####
  • ### - ### - ####
  • PROGRAM DESCRIPTION & GUIDELINES

    I understand that my child has the opportunity to attend the PREP after-school program activities Monday – Thursday, from the end of the school day until 6:00 PM. On minimum days the program will end 3 to 4 hours after the school day ends. Program operating hours and offerings may vary. Contact your Site Coordinator for the most current schedule.
  • CONSENT TO USE OF VIDEO OR PHOTOGRAPHY

    My signature below authorizes the PREP staff to photograph and/or film my child during the program and I hereby consent to use of these photographs in LEARN’s promotional material.
  • RELEASE OF INFORMATION

    My signature below authorizes the exchange of information regarding my child’s academic progress between the PREP staff and the staff at my child’s school.
  • LIABILITY WAIVER

    I hereby waive all claims against my child’s school district, the LEARN organization and its employees for injury, accident or illness occurring by reason of participation in the PREP Program. In case of an emergency, I authorize any 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.
  • This field is for validation purposes and should be left unchanged.

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