Romoland School District VOYAGERS Expanded Learning Programs Admission Form Program Hours Voyagers operates Monday through Friday until 6:00 p.m., beginning immediately after the end of the regular school day. Students must be picked up promptly at the end of the program day. Daily Operations Voyagers consists of three components per day: 1. Academic Hour- Tutoring and/or homework assistance *Students will have an opportunity to complete assigned homework as well. However, we do not guarantee that all homework will be complete and/or corrected.

2. Educational Enrichment- Positive youth development through S.T.E.A.M. (science, technology, engineering, art, and mathematics) activities to help reinforce Common Core and Next Generation Science Standards. 3. Recreation-Activities designed to promote physical activity, health and nutrition. *A nutritional snack and supper will be offered to each student daily. Child’s Legal Name: ____________________________________ Teacher’s Name ______________________________ Child’s Nick Name: ___________________________ Gender: _____________ Grade (2016-2017): _________________ School of Attendance: _______________________________________________________________________________ Home Address: _____________________________________________________________________________________ Has student been retained or recommended for retention? Yes / No if yes, what Grade?: _______ Is student at risk of retention? Yes /No Does your child have a special need? Yes / No if yes, please specify:___________________________________________ Does your child attend a regularly scheduled after school activity? Yes / No Please circle which activity and what day: Faith Based Education Tutoring Sports Other: ________________________________________________________ Monday Tuesday Wednesday Thursday Friday I authorize Romoland School District to photograph my child for the purposes of displaying within the school and District website. Please Circle one Yes / No Child Lives with (Please Circle All that apply): Mother Father Guardian Stepmother Stepfather Foster Parent Grandmother Grandfather Aunt Uncle Other: _______________________________________________________ Please list the names of any siblings who will be attending the program: _______________________________________ __________________________________________________________________________________________________ Home Language: ____________________________________ Primary (This person will be contacted first) Parent/Guardian ____________________________________ Phone Number _________________________________ E-mail_____________________________________________ Alt. Phone Number _____________________________ Secondary Parent/Guardian ____________________________________ Phone Number _________________________________ E-mail_____________________________________________ Alt. Phone Number _____________________________ __________________________________________________ Parent Signature

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Romoland School District VOYAGERS Expanded Learning Programs Student and Parent/Guardian Agreement Our Mission: Voyagers strives to prepare our students for their voyage through life by providing a safe expanded learning environment that encourages academic excellence, personal opportunities to succeed, positive peer and adult interactions and community involvement. Please read the following contract carefully with your child/ children. In order to enroll in Voyagers a parent and student signature must be present at the bottom of this page indicating understanding and consent.

Enrollment: Our hope is to service all students wishing to attend the Voyagers program. However, enrollment is limited to 100 students per site. Enrollment priority is based on the following criteria: 1. 2. 3. 4. 5.

Returning students (all students currently enrolled in R.E.B.E.L.S. who wish to maintain a priority status, must return their enrollment packet before May 23rd). Students who have been retained or recommended for retention (Retention status will be confirmed with front office). Students who are at risk for retention and students with low academic performance Siblings of students who meet criteria for 1,2 and/or 3. Other students who would like to participate, but not necessarily recommended for academic intervention.

Attendance: Students are expected to attend Voyagers daily and participate for the full program operating hours. They may only attend Voyagers on the days that they attend the regular school day. Unexcused/frequent absences or repeated unexcused early student release may lead to dismissal from the Voyagers program.

Homework: Students will have the opportunity to complete assigned homework during the Academic component of the program. We will make every effort to assist students in completing their homework within the allotted time. However, we do not guarantee that all homework will be complete and/or corrected. Homework completion remains the responsibility of the student and his/her parent/guardian. Students are expected to: 1. 2. 3.

Bring their homework daily Accept that other academic activities will be assigned if they arrive without appropriate homework Know that their teacher will be contacted if they repeatedly report that they were not assigned homework

Inappropriate Behavior: Participation in Voyagers is a privilege. Should any child choose to act in an undesirable manner they will be excused from the program. Discipline for inappropriate behavior will be dealt with on a case by case situation. When students engage in inappropriate behavior, the following consequences will most often be followed: 1. 2. 3. 4.

1st incident: Written warning 2nd incident: Behavior Contract 3rd incident: Suspension from the program 4th incident: Removal from the program

Student Pick-Up: Students must be picked up promptly at the end of program operating hours. Monday through Friday Voyagers operates from the end of the school day until 6:00 p.m. Only adults who are 18 years of age or older are permitted to pick up students. Students must be signed out by a parent/ guardian or authorized adult. All adults picking up children will be required to present a valid photo ID on a daily basis. Excessive late pick-ups may result in a student being dismissed from the program. If a student is not picked up and contact with any persons on the emergency card cannot be made, we may need to contact law enforcement for assistance.

Parent/Guardian Support: Voyagers encourages and invites parents/guardians to participate in our daily routines, field trips, events, and special activities. Parents wishing to volunteer a will be asked to follow Romoland School District’s policy for parent/ guardian volunteers. If at any time a parent/guardian or authorized adult displays disruptive behaviors, School Administration as well as law enforcement may be notified and the student may be dropped from the program.

I have read and understand all of the above information. I agree to follow all rules and to support Voyagers staff members in implementing the rules that have been set forth. ______________________________________ Parent Signature

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______________________________________ Student Signature

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Romoland School District VOYAGERS

Expanded Learning Programs Photo Release Child's Name___________________________ Date ____________________________ Romoland School District expanded learning staff will occasionally photograph children while participating in a Voyagers activity or event. The purpose of these photographs are to capture key moments in our program. Please circle either Yes or No for the statements below: I understand that my child may be photographed while attending the Voyagers programs. I authorize Romoland School District to utilize photos taken at the Voyagers program for the purposes of displaying with in the school site, the Romoland School District website, program specific social media, and possible newsprints.

Yes/ No ____________________________________ Parent Name (please print)

____________________________________ Parent Signature

Romoland School District VOYAGERS Expanded Learning Programs Emergency Information Child’s Name______________________________________ Age__________ Grade___________ Address__________________________________________________________________________________ Parent/Guardian ____________________________________ Phone Number ________________________ E-mail_____________________________________________ Alt. Phone Number _____________________ Parent/Guardian ____________________________________ E-mail_____________________________________________

Phone Number ________________________ Alt. Phone Number _____________________

Authorized Persons to contact in case of emergency: (All Authorized persons may be contacted in an emergency and may pick up my student at dismissal) Name_________________________________________ ____ Phone Number___________________________ Relationship_______________________________________ Alt. Phone Number _______________________ Name_________________________________________ ____ Phone Number___________________________ Relationship_______________________________________ Alt. Phone Number _______________________ Name_________________________________________ ____ Phone Number___________________________ Relationship_______________________________________ Alt. Phone Number _______________________ Medical Information: I authorize the staff of the after school program to perform necessary first aid. Y/N Your Signature below authorizes the School District to contact the physician listed below to render necessary emergency treatment for serious injury or accident (at your expense) if neither parent/guardian can be reached. This further authorizes the school district to take your child to a local physician of the school’s choice if your physician is not available. In the event emergency treatment is necessary, the school district will be held harmless in all decisions. Doctor’s Name_____________________________________ Insurance _________________________________________ Card Number _____________________________ My Child does not have medical insurance and I would like information on Student Accident Insurance Allergies/ Mental or Physical conditions___________________________________________________________

____________________________________________ Parent/Guardian Signature

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