Flipside Registration Form
Turn in to the main office bySept. 30 to start on time. Late forms will be accepted till 11/22/15.
STUDENT INFORMATION
Last Name: ______First Name: ______Student Number: ______
Grade: ____ Gender: ____ Birth Date (mm/dd/yy): ______Email Address: ______
PARENT/GUARDIAN INFORMATION
Name(s):______Phone: ______
Email Address:______
Emergency Contact: ______Relationship: ______Phone: ______
TRANSPORTATION
My child will: Walk Home_____ Be Picked Up_____ *Ride theAfterschool Bus_____
*Youth are eligible for afterschool transportation if they receive busing during for the regular school day.
Drop-Off Address (if different from home address): ______
PERMISSION STATEMENTS FOR AFTERSCHOOL PROGRAM PARTICIPATION
YES__NO__ I give my child permission to participate in the Flipside afterschool program.
YES__NO__MEDIA RELEASE:
I give permission for my child to be in photo or filming sessions of program activities that may be used for program or District promotions.
YES__NO__MEDICAL PERMISSION:
I give permission to secure the services of a licensed physician if I cannot be reached in the event of a medical emergency.
YES__NO__MEDICAL INFORMATION:
My child has medical concerns I believe you should know about such as prescriptions, food allergies, and/or medication allergies. If “YES”, please specify health condition/ medication:
______
YES__NO__PROGRAM EVALUATION
I give permission for my child’s participation included in program evaluation.[This program participates in the Sprockets network, which aims to improve the quality and availability of afterschool and summer programs for youth and their families in Saint Paul. Information about your child’s participation in this will be used to help assess the quality and effectiveness of out of school time programs. Information about your child will be kept confidential and your child will never be identified in any evaluation or research reports. You have the right to review the Data Privacy Notice.]
YES__NO__SURVEYS
I give permission for my child to participate in program-related surveys. [Your child may be invited to complete surveys about their experience in the afterschool program, which will help us to improve the program. Your child’s participation in all surveys is voluntary. Surveys will be available for review upon request to the Flipside Coordinator.]
YES__NO__WALKING FIELD TRIPS
I understand that WALKING field trips within one mile of school grounds may be part of classroom curriculum. Necessary precautions and supervision will be provided.
______BEHAVIOR
Parent InitialsI understand that expectations for the After School Program are the same as the expectations during the school day. My child will follow rules and expectations in school and on the bus.
______PERSONAL PROPERTY
Parent InitialsI understand the Saint Paul Public Schools will not be responsible for lost or stolen items.
I attest that I (parent name) ______am the parent/guardian of (student name)______. My signature below signifies that I understand the statements above.
______
Parent SignatureDate
Schedule Request Form
Fall Session runs October 12 – January 28. Class descriptions can be found online.
Student Name: ______Lunch Number: ______
Directions: Mark your top THREE choices (1, 2, or 3) for EACH box.
*Classes fill up quickly; having alternate options ensures enrollment in program.*
MONDAY & WEDNESDAY OPTIONS
____ Not Attending Mon/Wed
____ Anime Club2-3 pmMs. Reese, Murray Middle
____ Athletic Training3-4pmMs. Atchison, Murray Middle
____ Board Games Club2-4 pmMr. Kennedy, Community Expert
____ Boys Group (Mon-Thurs)2-4 pmMr. Farley & Mr. Little, Murray Middle
____ Debate Club3-4 pmMs. Novak & Alejandro, Murray Middle
____ Debate League2-3 pmMr. Dahlberg, Murray Middle
____ Design Team2-4 pmMs. Rose & Mr. Jason, Science Museum of MN
____ Girls Group2-4 pmMs. Pittman & Ms. Vaughn, Murray Middle
____ Leadership Crew2-3 pmMs. Kenya, JK Movement
____ Lego League (FULL)2-4 pmMr. Altringer, First Lego League & Murray Middle ____ Murray for All 3-4 pm Ms. Kopas, Community Expert
____ Newspaper Club (FULL)3-4 pmMs. Lund, University of MN
____ Painting Class2-4 pmMs. Bush, University of MN
____ Rock Band (auditions req’d)2-4 pmMr. Barta & Mr. Rockwood, Community Experts
____ Study Hall (CANCELLED)2-3 pmMs. Pischke, Murray Middle
____ Yoga & Classical Stretch2-3 pmMs. Morrison & Ms. Scheid, Murray Middle
TUESDAY & THURSDAY OPTIONS
____ Not Attending Tues/Thurs
____ Athletic Training (FULL)3-4 pmMs. Pischke, AmeriCorps
____ Boys Group (Mon-Thurs)2-4 pmMr. Farley & Mr. Little, Murray Middle
____ Breakdance Crew (FULL)2-3 pmMs. Edna, Universal Dance Destiny
____ Chess Club3-4 pmMr. Dahlberg, Murray Middle
____ Fashion Design (FULL)2-4 pmMs. Lisa, East Side Arts Council
____ Guitar Lessons (FULL)2-3 pmMr. Rockwood, Community Expert
____ Hip-Hop Crew3-4 pmMs. Edna, Universal Dance Destiny
____ History Day Prep2-3 pmMr. Beck, Murray Middle
____ JA Biztown2-3 pmMs. Halperin, AmeriCorps
____ Minecraft Club (FULL)3-4 pmMs. Jones, Murray Middle
____ Star Wars Club2-4 pmMr. Kennedy, Community Expert
____ Study Hall (FULL)2-3 pmMs. Pischke, Murray Middle
____ Youth Advisory Council2-4 pmMs. Atchison, Metropolitan State University
Program is sponsored by the Saint Paul Public Schools Community Education Department and is funded with a grant from the Minnesota Department of Education using federal funding, CFDA 84.287c, 21st Century Community Learning Centers.