\<~'-~ Sincerely, Lisa Zavota

Transcription

1 \<~'-~ Westside's Night Alive (WNA)/Campbell's Night Alive (CNA) Lisa Zavota Project Director 1210 Jimmy Ann Drive Daytona Beach, Florida ext Greetings: I am the project director for the 21 st CCLC grant that runs afterschool and summer programs at Campbell Middle School and Westside Elementary School. Our program runs from August 20, 2012 through June 4, We would like to extend an invitation to your students to participate. I have enclosed applications for you to copy and distribute. Grades K-S are eligible for the program at Westside and grades 6-8 are eligible for the program at Campbell. Please let me know if you have any students that are interested in joining us. Sincerely, Lisa Zavota

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3 Campbell's Night Alive (CNA) 21 st Century Community learning Center (CClC) Student Registration Application Usa Zavota (Program Facilitator ext 52453) Nicholas Fidance ( Site Coordinator) Student's Grade Level : Student's Last Name: i Student's Address: Student's Date of Birth: Prima isho isho Othero Head of Household: Mother 0 Father 0 Botho Mother's Name Mother's Father's Name Father's Address: Father's Siblings that currently attend THIS school: Mother's Cell Phone: Mother's Home Phone: Father's Cell Phone: Father's Home Phone: Father's Work Phone:.:..===~ The CNA program is an extension of the school day. Therefore all school rules are in effect. Failure to follow the rules could result in disci action u to and includin removal from the ram. Parent Signature: Date: ******************* PLEASE TURN OVER AND COMPLETE BACK OF FORM**************************

4 School District of Vol usia County Media Production Release Autborization I. -::-:---.-::_--::-:::--.--:-- -" hereby assign all rights to the photographs, video and I or Print Name ofparticipant sound recording made of me to the SCHOOL BOARD OF VOLUSIA COUNTY, FLORIDA, for the school year,. I hereby authorize the performance, display and reproduction of pictures and sound contained in any production, without limitation as an educational resource. I hereby waive any right to inspect or approve the finished photographs, sound track/video, or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that might be applied. I agree that the producers, the SCHOOL BOARD OF VOLUSIA COUNTY, representatives, and assigns are released from any liability for claims arising out of the use of photographs and/or sound/video recording in any production. I certify that I am over 18 years of age. or have the expressed consent/permission of parent or guardian, Participant Signature Parent or Guardian Signature Parent or Guardian -- PRINT Name nate School~ RfiiIod 8101 DiJtribuled by StaffDneIopment ami Media Services 2002~81 ves

5 Westside's Night Alive (WNA) 21 st Century Community learning Center (CClC) Student Registration Application Lisa Zavota (Program Facilitator ext ) Michael Micallef (Site Coordinator) Student's Grade Level : Student's Last Name: Student's Address: Student's Date of Birth: nisho Othero Head of Household: Mother 0 Father 0 Botho Mothers Name Mothers Address: Mothers Fathers Name Fathers Address: Fathers Siblings that currently attend THIS school: Free luncho Mothers Cell Phone: Mothers Home Phone: Mothers Work Phone: Father's Cell Phone: Fathers Home Phone: Fathers Work Phone: Wl:I\Jrrnont 0 Does your child have any special medical concerns that we need to be aware of? Allergies? Medication? Other? Please explain: Behavior: In order to promote a productive learning environment all students will be expected to follow rules and procedures of the 21 st CClC and the Volusia School Department. Children that behave inappropriately will be treated in a fair, firm manner. Consequences will include: cool down writing, time out warning, program!i:1j~:n"in!i:ill'ln_ and for serious or infractions. Parent Signature: Date: UUUU***U*U*** PLEASE TURN OVER AND COMPLETE BACK OF FORM***u**u*uu****u*uu*

6 Scbool District of Volusia County Media Production Re1ease Autborization I, --=-:--:-::----::-:::---:-:-, hereby assign all rights to the photographs, video and I or Prim Name ofparticipant sound recording made of me to the SCHOOL BOARD OF VOLUSIA COUNTY, FLORIDA, for the school year. I hereby authorize the performance, display and reproduction of pictures and sound contained in any production, without limitation as an educational resource. I hereby waive any right to inspect or approve the finished photographs, sound tracklvideo, or advertising copy or printed matter that may be used in conjunction therewith or to We.~ventual use that might be applied. I agree that the producers, the SCHOOL BOARD OF VOLUSIA COUNTY, representatives, and assigns are released from any liability for claims arising out of the use of photographs and/or soundlvideo recording in any production. I certify that I am over 18 years of age, or have the expressed consent/permission of parent or guardian. Participant Signature Parent or Guardian Signature Parent or Guardian -- PRINT Name Date School Rovioed BIOI DiJtributed by Stafl'Dewlopmlllt and Media SemQea ves