Tarrant County College South Campus Generation Hope Student Application

Transcription

1 Tarrant County College South Campus Generation Hope Student Application Requirements FOR NEW APPLICANTS: Parental Permission Completed application 1 Essay 2 Teacher Recommendation Copy of last year s report card Attend program orientation session Requirements FOR RETURNING APPLICANTS: Parental Permission Completed application Generation Hope is "first-come, first-serve", make sure your application is complete and submitted! DIRECTIONS 1. Complete the application in black or blue ink 2. Essay - please print in ink or type a word essay answering the following question: What do you hope to gain from Generation Hope? 3. Submit your completed application: a. Scan and to generation.hope@tccd.edu b. Fax to c. Mail to or deliver to: Tarrant County College South Campus Attn: Generation Hope/Erika Zimmermann Community and Industry Education 5301 Campus Drive Fort Worth, Texas You can expect to receive a response within a week of submitting your application. If you have any questions, please contact Erika Zimmermann at or generation.hope@tccd.edu TCC and the Generation Hope Program are an Equal Opportunity Institution/Equal Access to persons with disabilities. FOR OFFICE USE ONLY RECEIVED INIT. COMPLETE / INCOMPLETE INCOMPLETE CODES: ( ) A ( ) E ( )G ( ) N SCIENCE DATE COMPLETED: / / ENGLISH INIT. MATH / / / NOM. ESSAY: YES / NO CONDUCT ACCEPT: BY:

2 PERSONAL INFORMATION Legal Name: Last Gender: Male Female Generation Hope Student Application First of Birth District ID number: Ethnicity: American Indian Anglo African American Hispanic Asian Other Mailing Address City State Zip Home Phone CURRENT SCHOOL INFORMATION Grade Level: Full Name of School PARENT / GUARDIAN INFORMATION Name Public School District You Live In Relationship Middle Initial Mailing Address (if different from applicant): Home Phone Work Phone Cell Phone Address Does child reside with you? Yes No N/A Extension EMERGENCY CONTACT INFORMATION Name Mailing Address (if different from applicant): Home Phone Cell Phone Work Phone Relationship Extension PARENT / GUARDIAN'S PERMISSION Please initial to show your agreement with each of the following statements: I am the parent/legal guardian of the student named above. I understand Generation Hope is a rigorous and demanding program that requires the ability and motivation to complete complex class work and homework above and beyond standard school instruction. I give permission for my child to attend Generation Hope. I understand my child must attend Generation Hope two days a week from October to May. I understand that there is a maximum of THREE excused absences. I also understand that she/he will have classwork and/or homework daily. I understand my child must follow all Generation Hope and school district rules. I understand Generation Hope has a zero tolerance policy regarding noncompliance with all Generation Hope and/or school district rules and policies. In the event of a rule/policy violation, the director may dismiss the child from the program. Some examples of rule violations include but are not limited to: cheating, plagiarism, leaving campus without permission, damaging property, physical violence, setting off fire alarms, or repeated patterns of less serious violations. I understand I am responsible for my child s transportation arrangements, if they do not ride the bus. Parent/Guardian Signature Student's Signature

3 Generation Hope TEACHER NOMINATION FORM DIRECTIONS: Please return this form to the student upon completion. It must be attached to the rest of his/her application and submitted to Generation Hope. PART 1 - TO BE COMPLETED BY APPLICANT Full Legal Name: LAST FIRST MI Current Grade Level: School Attending School District PART 2 - TO BE COMPLETED BY THE TEACHER Generation Hope is a rigorous and demanding program designed for motivated students with the ability to successfully learn and complete complex class work and homework above and beyond standard school instruction. He/she is being considered for admission to Generation Hope. Please give us your honest assessment of this student s desire and ability to learn. A. PLACE AN "X" IN THE APPROPRIATE COLUMN FOR EACH CHARACTERISTIC LISTED. CHARACTERISTIC EXCELLENT GOOD FAIR POOR ACADEMIC PERFORMANCE CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME ANALYTICAL THINKING SKILLS MATURITY PUNCTUALITY EAGER TO LEARN NEW THINGS STUDENT IS SUFFICIENTLY MOTIVATED TO COMPLETE AN AFTERSCHOOL PROGRAM B. Please provide comments on motivation, behavior, personality, strengths or weaknesses you feel are pertinent to the student s performance in Generation Hope. Additional comments may be written on the back. C. Current course you are teaching applicant TEACHER'S PRINTED NAME/TITLE SCHOOL TELEPHONE NUMBER TEACHER'S SIGNATURE DATE

4 Voluntary Minor Student Health Information and Consent to Emergency Treatment Name: DOB: : Campus: TCCD Student ID: Parent/Guardian: Home #: Cell #: Work #: Parent/Guardian: Home #: Cell #: Work #: In case of an emergency and parents cannot be reached, who should be contacted? 1. Name : Relationship to Student: Home #: Cell #: Work #: 2. Name : Relationship to Student: Home #: Cell #: Work #: Physician: Phone #: Preferred Hospital: Phone #: Allergic to (meds, food, insects, etc.): Type of reaction (rash, difficulty breathing, etc.): Current medical diagnoses or disabilities: Past injuries/illnesses/hospitalizations/surgeries: List any medications currently taking below. Medications Strength Dose Time Given: Consent to Emergency Treatment Tarrant County College District is an educational institution in which, a student, at the College has received written authorization to consent to emergency medical treatment from a person having the right to consent as follows: I,, the [relationship to student] grant Tarrant County College permission to authorize emergency medical treatment to the above named student in the event that the College is unable to contact me. This authorization shall remain in effect until revoked by me in writing and delivered to TCCD. The undersigned is responsible for all medical costs associated with this authorization. Furthermore, no liability is attached to either TCCD or any of its members and staff for such action. Signature of Parent or Legal Guardian Tex. Family Code

5 Informed Consent and Assumption of Risk Form This form needs to be signed by all participants, students, guests, and other non-employees participating in act i vi t i es o r even t s. Students/ Participants under the age of 18 are required to obtain a signature from a parent or legal guardian. (INSERT NAME OF ACTIVITY OR EVENT) RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I, ("Participant"), hereby acknowledge that I have voluntarily elected to participate in the following activity or event (the "Activity"), to be held in and around the following location,on. In consideration for being permitted by Tarrant County College District (the "DISTRICT") to participate in the Activity, I hereby acknowledge and agree to the following: RULES AND REQUIREMENTS: I agree to conduct myself in accordance with DISTRICT policies and procedures. I further agree to abide by all the rules and requirements of the Activity. I acknowledge that DISTRICT has the right to terminate my participation in the Activity if it is determined that my conduct is detrimental to the best interests of the group, my conduct violates any rule of the Activity, or for any other reason in the DISTRICT's discretion. Failing to follow rules of the Activity, staff directors, or the Student Handbook may result in disciplinary action. If I am told to leave the Activity as a result of my failure to follow the rules and requirements of the Activity or the directions of the staff directors, transportation from the Activity will be at my expense. INFORMED CONSENT: I have been informed of and I understand the various aspects of the Activity, including the dangers, hazards, and risks inherent in the Activity, including but not limited to transportation to and from the Activity and/or the DISTRICT via private vehicle and/or common carrier, participation in the Activity, overnight accommodations, weather conditions, conditions of equipment, facility conditions, negligent first aid operations or procedures, and in any independent research or activities I undertake as an adjunct to the Activity. I understand that as a participant in the Activity I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only DISTRICT's actions or inactions, but also the actions, inactions, negligence or fault of others and despite safe precautions, DISTRICT cannot guarantee safety thereof and all risks cannot be prevented. RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE,DISCHARGE, AND COVENANT NOT TO SUE DISTRICT, its governing board, directors, officers, employees, faculty, agents, volunteers and any participants or students (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of action

6 (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Activity, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON,UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY,OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any injury or damage that Isustain as a result of my own negligent acts. ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation in the Activity, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage, or even death. I understand that there are potential risks as a consequence of, but not limited to: participation in this Activity, travel to and from DISTRICT via private vehicle or common carrier, weather conditions, overnight accommodations, facility conditions, equipment conditions, first aid operations or procedures of Releasees, and other risks that are unknown at this time. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OR OMISSIONS OF THE RELEASEES and assume full responsibility for my participation in the Activity. INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all cost, expense or liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage, or death that I may suffer as a result of my participation in the Activity. FERPA: I consent to the release of my records that are protected by the requirements of the federal Family Educational Rights and Privacy Act (20 U.S.C. Sec. 1232g, 34 CFR Par.99), but only in conjunction with the Activity, and I release the Releasees from any and all damage and liability, including any and all claims, demands, causes of action (known or unknown), suits or judgments of any and every kind (including attorney s fees) arising from any damage, cost or expense I may suffer or incur as a result of the release of such records. PERSONAL MEDICAL INSURANCE: I further acknowledge that I am responsible for the cost of any and all medical and health services I may require as a result of participating in the Activity. CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I am physically and mentally fit to participate in the Activity and that I do not have any medical record of history that could be aggravated by my participation in this particular Activity. If I require any reasonable accommodation(s) in order to participate in the Activity, I have notified the sponsor in writing of the nature of the accommodation(s) needed prior to the Activity. MEDICAL CONSENT: I understand and agree DISTRICT is not responsible for my health and safety. Recognizing this, however, I wish to, and hereby do, grant DISTRICT full authority to take, or not to take, in its sole discretion, whatever actions it may consider warranted under the circumstances for my health and safety during my participation in the foregoing event, and I hereby release it from any liability for any such decisions or actions as may be taken in connection therewith. The authority granted in the preceding sentence shall include the right (in the sole discretion of DISTRICT) to place me, at my own expense, and without any further consent, in a hospital, for medical services and treatment, or if no hospital is readily accessible, to place me in the hands of a local medical doctor for treatment. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment. CHOICE OF LAW: I hereby agree that this Agreement shall be construed in accordance with the laws of the State of Texas. SEVERABILITY: If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby.

7 I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND IHAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT IAM AT LEAST EIGHTEEN YEARS OF AGE OR, IF NOT, THAT IHAVE SECURED BELOW THE SIGNATURE OF MY PARENT OR GUARDIAN AS WELL AS MY OWN. Name of Participant TCCD Student ID Number Signature of Participant Signature of Parent/Guardian for Participants under eighteen (18) years of age: I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with Participant in granting a release to Releasees as set forth in detail above. Signature of Parent or Guardian EMERGENCY CONTACT: Name: Relationship: Phone Number: