2020-2021 ACE Registration

ACE After School Registration - MLK
August 31st, 2020 - May 22nd, 2021
Parent/Guardian Information
Name*
First NameLast Name
Primary Number*
Area CodePhone Number
E-mail*
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Emergency Contact's Name*
First NameLast Name
Relationship*
Phone Number*
Area CodePhone Number

Student Information
Student Name*
First NameLast Name
Birth Date*
MonthDayYear
Incoming Grade*
Gender*
MaleFemale
Student Race/Ethnicity*
Please list any known allergies
Please describe any special needs or concerns regarding your child
Are you signing up another child?*
YesNo

Student 2 Information
Student Name
First NameLast Name
Birth Date
MonthDayYear
Incoming Grade
Gender
MaleFemale
Student Race/Ethnicity
Please list any known allergies
Please describe any special needs or concerns regarding your child
Student 3 Information
Student Name
First NameLast Name
Birth Date
MonthDayYear
Incoming Grade
Gender
MaleFemale
Student Race/Ethnicity
Please describe any special needs or concerns regarding your child
Please list any known allergies
Student 4 Information
Student Name
First NameLast Name
Birth Date
MonthDayYear
Incoming Grade
Gender
MaleFemale
Student Race/Ethnicity
Please describe any special needs or concerns regarding your child
Please list any known allergies

Distance Learning
If you do not have access to internet, there is still an opportunity to participate in our programs. We will reach out directly to you for more information.
Does the participant have access to reliable internet?*
YesNoSometimes
Does the participant have access to a laptop, tablet, or phone?*
YesNoSometimes
Commitment
It is the responsibility and commitment of the participant to participate in the activities offered online & through the packets. Attendance will be required to continue receiving materials.

After School Behavior Agreement
The staff at ACE is dedicated to giving you the most valuable, safe, educational, memorable, and FUN afterschool experience, even with the new distance learning space. Please review our policies with your child(ren) before signing below.
Rules:
1. Use safe online practices
2. Be respectful to staff, students, parents, and equipment
3. Use appropriate language and behavior
4. Participate and contribute your ideas and thoughts
5. Have fun! 😊
Anti-Bullying Policy: Bullying of any kind in our programs will not be taken lightly. ACE has ZERO TOLERANCE for violent, physical and/or verbal outbursts. Children displaying physical behavior or who engage in bullying will be required to attend a parent conference meeting before attending additional afterschool classes.
Staff will follow these disciplinary steps for each instance of misbehavior
Strike 1
Verbal Warning – instructor signals the student to change his/her behavior
Strike 2
Student will be removed from virtual or in-person class. Staff member will inform parents.
Strike 3
Student will receive a write-up detailing behavior & will be required to attend a parent conference before returning to after school activities.
Strike 4
If behavior continues or if behavior is severe a behavior agreement will be created with the student and parent and will need to be upheld in order to continue attending after school.
Strike 5
If behavior agreement is broken, student may not be removed from after school activities
I have read and understand the rules and consequences for failing to follow the rules. I understand that participants who refuse to comply may result in disciplinary action, which can include sitting out from participating, suspension from ACE, or expulsion. I have also reviewed the policies with my child(ren) and explained the possible disciplinary actions to them.
Initials*

CONSENT FOR SERVICES/GENERAL RELEASE OF LIABILITY
I, the undersigned parent/guardian, agree that my child can participate in the services provided by East Austin Prep. (“EA Prep”). I understand and agree that my child’s participation in these services may be disclosed on a need to know basis to other entities engaged in providing services to my child.
I release EA Prep from all liabilities to my child for all damages, expenses (including attorney fees), claims, judgments, actions or causes of action as a result of any loss or injury to the person or property which my child may sustain or suffer during or arising out of services provided by EA Prep or transportation provided by EA Prep, whether caused by the acts or omissions of EA Prep officers, directors, employees, representatives, advisors, affiliates, divisions, departments, related entities, contractors, funding source and/or other agents (“Parties Released”). I agree to defend and indemnify the Parties Released from and against any and all liabilities.
I, the undersigned parent/guardian, hereby give my consent for the release of reports, stories, videos, or pictures (“Materials”) that may identify my child. These Materials may be used for educational, informational, promotional, marketing or other activities. I acknowledge EA Prep’s right to prepare the Materials for publication or other use, including cropping, altering or changing the Materials at its discretion. I hereby release the Parties Released from all claims and liabilities arising out of or in connection with the use of the Materials. I understand that I do not have a right to royalties or payment in any form for these Materials, neither today nor at any future date.
I hereby give permission for the participant(s) listed on this application to take part in the East Austin College Prep: ACE activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I understand that all of EA Prep policies and procedures are to be adhered in this program. My child is expected to behave appropriately at all times and follow the rules of your school. I also acknowledge that I have received the Parent Handbook, which describes the East Austin College Prep: ACE Program Behavior Management Policy in more detail.
I further give my consent to the school district and East Austin College Prep: ACE to share the participant’s student records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and /or East Austin College Prep: ACE will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program.
Vendor and/or Partner Information Sharing
East Austin College Prep: ACE contracts with non-EA Prep organizations to provide afterschool activities. I give the afterschool staff permission to release my child’s student ID # to EA Prep’s contracted program providers for the purpose of assessing program effectiveness. Only group data (i.e. information regarding state test scores, attendance, behavior, etc. for all the students in the program) will be examined, no data specifically connected to your student will be identified.
I give consent to share my child's information with partners*
YesNo
Photo/Video Taping Release
I give my consent to the East Austin College Prep: ACE program to take the participant’s photograph or videotape during program activities, to be used for educational and public relations purposes.
I give consent to take and publish my child's photos or videos.*
YesNo
Text and Email Notifications
I give the afterschool staff permission to contact me through the Remind app and email for updates regarding programming, time/date changes, upcoming events, etc.
I give consent to be added to the ACE email and texting list*
YesNo
Signature
I am the parent/legal guardian of the minor named above and have legal authority to execute this consent & release. Grievances related to the program may be addressed by a phone call or conference with, the East Austin College Prep ACE Director or school principal. For unresolved matters, please refer to EA Prep’s Student Handbook for additional resources and/or www.eaprep.org for school district protocol.
I agree that I have signed the consents on this form in exchange for my child’s participation in services provided by EAPrep. Additionally, my signature affirms: (1) that I have read this document and have been offered a copy of this document; and (2) that the parent/guardian identified in this form is the parent or legal guardian of the child identified in this form.
Parent Signature *
Clear
Should be Empty:

ACE After School Registration - MLK

Commitment