SavetheChildren
Calhoun County Schools is very excited that we will again be offering our ASPIRE afterschool program through our 21st Century Community Learning Grant along with the support of our Save the Children partnership at all three schools in Calhoun County. The afterschool program will run from 3:30-5:45 for CMHS students and from 3:30-6:00 for the elementary schools. Transportation will be provided along the main route traveling to the north and south ends of the county. Supper will also be provided each evening to students. Students at CMHS will receive homework help, tutoring, literacy, and enrichment “camps” gauged by students’ interests. At the elementary level, students will have homework help, math, reading, healthy choices, and STEAM. STEAM is science, technology, engineering, art, and math. We are very excited to have this grant and opportunities it will provide our students. Please consider this awesome opportunity for your child!
Please send back your enrollment packet as soon as possible. ASPIRE afterschool programs will begin August 22, 2017!
SavetheChildren
Afterschool Program Student Registration Form for School Year 2017-2018
STUDENT INFORMATION
Name: ______Grade: ______Sex: _____
Address: ______City: ______Zip: ______
PARENT/GUARDIAN INFORMATION
Father: ______Home #: ______Work: ______Cell: ______
Mother: ______Home #: ______Work: ______Cell: ______
Guardian: ______Home #: ______Work: ______Cell: ______
Student lives with (check all that apply): [ ] Father [ ] Mother [ ] Guardian
EMERGENCY CONTACTS
In the event that parents/guardians cannot be reached in an emergency, the afterschool program will call a person listed below. People listed should be individuals who can: 1) give permission to administer health care 2) pick up your child if ill or 3) give advice about caring for your child.
Name: ______Name: ______
Address: ______Address: ______
Home #: ______Work #: ______Home #:______Work #:______
Cell #:______Relationship ______Cell #:______Relationship ______
STUDENT PICK UP
Please list additional people who you authorize to pick up your child(ren) from the afterschool program.
Name:______Name: ______
Address: ______Address: ______
Home #:______Work #:______Home #:______Work #:______
Cell #:______Relationship: ______Cell #:______Relationship: ______
BUS INFORMATION
Please tell us where your child will be getting off the bus: ______
______
HEALTH INFORMATION
Physician: ______Phone: ______
Medication(s) being taken by student ______
Physical conditions (allergies, diabetes, etc.) ______
If my child’s emergency contacts listed above, or the physician listed above, cannot be reached in an emergency, I authorize an afterschool employee or legal representatives to obtain emergency medical care for my child while under the afterschool program’s care including transporting or sending my child to an available hospital or physician.
Signature______Date:______
ASPIRE CALENDAR
2017-2018
Arnoldsburg School ASPIRE Coordinator: Kelley Sampson
Calhoun Middle High School ASPIRE Coordinator: Deborah Toppings
Pleasant Hill School ASPIRE Coordinator: Kristie Ritchie
August 2017 / September 2017 / October 20178/22, 8/24 / 9/5 - 9/7 / 10/2 – 10/5
8/28 – 8/31 / 9/11 – 9/14 / 10/9 – 10/12
9/25 – 9/28 / 10/16 – 10/19
10/30, 10/31
November 2017 / December 2017 / January 2018
11/2 / 12/4 – 12/7 / 1/2 - 1/4
11/6 – 11/9 / 12/11, 12/12, 12/14 / 1/8 – 1/11
11/27 – 11/30 / 12/8 – 12/21 / 1/16 – 1/18
1/22 – 1/25
February 2018 / March 2018 / April 2018
2/5 – 2/8 / 3/1 / 4/4, 4/5
2/12, 2/13, 2/15 / 3/12 – 3/15 / 4/9 – 4/12
2/20 – 2/22 / 3/19 – 3/22 / 4/16 – 4/19
4/23 – 4/26
4/30
May 2018
5/1 – 5/3
5/7, 5/9, 5/10
Steven L. Paine, Ed.D., State Superintendent
1900 Kanawha Blvd., East, Building 6
Charleston, WV 25305
2017-2018 Evaluation of West Virginia’s
21st Century Community Learning Center Program
Parent/Guardian Informed Consent
I understand that the afterschool program my child will attend will be evaluated by the West Virginia Department of Education (WVDE). The Purpose of the evaluation study is to find out how well the program is working. What the WVDE learns from this study may help improve the program in the future. Later this school year, we would like to ask your child’s teacher about the amount of progress your child has made. Any information we would gather would be protected and your child would never by identified. The information provided would be combined with information from others, and reported as a group.
Allowing your child to take part in this study in the way just described will put your child at no more risk than he or she would experience during any normal day. Although your child may not benefit directly by being part of the study, it is possible that because of what we learn, the program may improve to better meet his or her needs or the needs of other students.
Neither you nor your child will receive any money or other reward for taking part in this study. Allowing your child to be part of the study is completely voluntary. If you decide not to allow your child to be part of it, there will be no penalties or loss of benefits to you or your child.
To allow us to collect this information from your child’s teacher there is no action you need to take. Thank you!
If you do NOT want your child to be part of the study, just fill in the information below and return this form to the afterschool program coordinator.
Do NOT include my child in the evaluation study.
Child’s name (please print): ______
Parent/guardian signature: ______Date: ______
Name of afterschool program: (to be filled in by program staff) ______
For more information about the education program we are studying, you may contact Josh Asbury (304-872-6440, ) or Benitez Jackson (304-256-4712, ). If you have questions about this evaluation study, you may contact Patricia Hammer (304-558-2546, ). This study has been reviewed and approved by the West Virginia Department of Education Institutional Review Board (IRB-WVDE-XXX). If you want to know more about the review of this study, you may contact the WVDE IRB co-chair, Amber
Calhoun County
Dear parent or guardian:
These questions are optional to complete, for all completed questions names, student ID numbers, or any
other identifying process will not be used. If you have any questions, please contact Jeannie Bennett at 304-
354-7011, ext. 318 or by email at .
DEMOGRAPHIC QUESTIONS CHECK ON THE LI
OVERALL IMPRESSIONS
Sex ______Male ______Female
______
Race/Ethnicity
______
American Indian or Alaska Native ______
______
Asian ______
______
Black or African American ______
______
Hispanic or Latino ______
______
Native Hawaiian or Pacific Islander ______
______
White ______
______
Two or More Races ______
______
No Information Provided ______
______
POPULATION SPECIFICS
Limited English Language Proficiency ______Yes ______No
Eligible for free or reduce priced lunch ______Yes ______No
Special needs (Students who have a current IEP (Individual Education Program) or 504 Plan (Section 504 of the Rehabilitation Act of 1973) who need to have their goals, services and accommodations/modification addressed as appropriate.) ______Yes _____ No