The Teen Spot Enrollmen...

The Spot Enrollment Form

Student Name (Last, First)

Preferred Name / Nickname

Gender

Grade

School

Please list any allergies or medical concerns.

Date of Birth

Teachers

List any academic or social challenges we can help with!

Transportation

My child needs transported home and I consent to transportation.

My child does not need transported home.

I consent to my child being transported for field trips.

I do not consent to my child being transported for field trips.

Address

Parent Name (Last, First)

Phone

Email Address

Parent Name (Last, First)

Phone

Email Address

Emergency Contact Name (Last, First)

Phone

On occasion, our program coordinator will share our activities and program projects on the program website, social media accounts, and in presentations to our funders with the use of activity descriptions and participant photos. Students will be made aware of when photographs will be taken, and will have the opportunity to opt out of photos at all times. I give permission for my student to be photographed for use on Highlands Partnership Network accounts, publications and activity promotions.

At “The Spot”, we will be interacting with your student, class and teacher to support them in achieving their academic, post-secondary, future career and attendance goals. In order to have the most impact and be of the most assistance, we may need to speak to your teacher about your student’s assignments, upcoming tests or other academic goals. “The Spot” staff will not discuss your child/children’s academic record, attendance, challenges or other personal information outside of the program or with anyone other than you (parent / guardian) and the student’s teacher(s). I authorize Highlands School District to release information contained in my student’s file. This information may include assessment results, attendance, demographics, goals and all programmatic paperwork. I understand that the information will help the interdisciplinary team in implementing my educational plan. I understand that the information may be shared in dialog in both oral and written form. My educational team consists of the following persons: Highlands Partnership Network The Spot for Teens staff (Instructors, support staff) Additionally, this program is funded through Allegheny County Department of Human Services Out-of-School Time program funds. In order to be accountable for this funding, we collect attendance and demographic data. Please review the following: I consent to share my child/children’s name, school attended, grade level, date of birth, and days attended with The Department of Human Services (DHS) for data tracking purposes. I understand that this information will be shared with DHS in order to secure appropriate data to fund my child/children appropriately throughout the sessions. I understand that legally I am NOT required to consent to the release of information. I voluntarily give permission in order to help my educational team provide the best service to me. This release expires one (1) year from the date of the signature and I may request permission to be revoked at any time.

I PERMIT MY YOUTH TO PARTICIPATE IN THE FOLLOWING SELECTED ACTIVITIES: The Teen Spot afterschool program is designed to support our community’s youth with their academic goals, future plans, social wellness, health goals and cultural identity. The program is available during the school year and in the summer. It is headquartered at 1428 Broadview Boulevard, Natrona Heights PA 15065 (in the Natrona Heights Presbyterian Church). Planned activities, projects and informational sessions through the program year may include:

Mentoring / Tutoring (All staff and volunteers have required clearances and training)

Drivers Education (separate parent permission forms will be required; student academic and attendance goals must be met)

Allegheny County Health Department Presentations / Information (sex education; intimate partner violence awareness; overdose prevention; addiction awareness; drug use prevention)

Physical and Mental Health Awareness (support groups)

Arts Education (music, art)

Field trips (will require permission form when scheduled to participate)

Thank you! We’ll be in touch.

The Teen Spot for Grades 6 to 12

The Spot Enrollment Form