Registration Form s15

After School Enrichment Program, Fall 2017 Registration Form Classes Run for six weeks on Tuesdays from October 10 – November 21* *No class November 7, student holiday. Class dates are: Oct 10, Oct 17, Oct 24, Oct 31, Nov 14, Nov 21.

REGISTRATION CHECKLIST: (No on-line registration) REGISTRATION FORM DUE MONDAY, OCTOBER 2

• Registration or Scholarship Application– completed and signed – PLEASE PRINT LEGIBLY • Emergency & Permission form – completed and signed • $5 check payable to “EMES PTA” for ASEP registration • Check made out to the instructor for $45 plus any additional supply fee required, as listed in the class description • Place all items in an envelope and return to school to the Attention: PTA ASEP *We will ensure the instructor receives their payment prior to the first day of class, once we confirm your registration is complete.

General Program Information  Classes run on Tuesdays, Oct 10 – Nov 21*, from 2:45-3:45 p.m. (*No class Nov 7, student holiday)  Registration is first come, first served (All forms must be completed to register your child)  PAYMENT: You must write two checks: one to instructor and one to EMES PTA, as follows: o Instructor payment: Check payable to instructor is equal to $45 for registration (except for Pinterest club, which is $60, as it includes a $15 supply fee) o Registration fee: Check of $5.00 per student, payable to EMES PTA  Scholarships are available; please complete the scholarship registration request form  Emergency contacts must include someone who can pick up your child if we cannot reach you  ASEP pickup time is 3:45 sharp. This is a program requirement. On any class day, if you have not picked up your child by 3:50, you or your emergency contact will be called to pick up your child.  WEATHER: ASEP classes are cancelled when there is early dismissal or evening activities are cancelled; the ASEP program follows the LCPS schedule  When an emergency cancellation occurs, you will be contacted by the instructor or ASEP to change after school directions for your child  NO REFUND AFTER SESSION BEGINS (Classes may be cancelled prior to first session if enrollment is low.)

*DEADLINES: Registration begins Friday, Sept 22 & ends Monday, Oct 2, 2017 After School Enrichment Program, Fall 2017

Student Name______Grade _____Teacher______

**To register, please Circle the class your child would like to attend. Please use a separate form for each child. ** CLUB NAME Description/Location (Class minimums and maximums) Grades This high-energy club has students playing fun games while learning new skills SPORTS MIX CLUB and making new friends. A different sport will be covered each week with games 3rd to complement what the students have learned. MEETS IN GYM with Mr. Mark Bauer 4th Club Minimum: 12, Maximum: 30 5th Precursor to the Sports Mix club, for grades 1-2. We will focus on the INTRO INTO SPORTS development of skills for multiple sports over a six-week period, including the 1st ACTIVITIES skills of Over and Underhand throws, catching, kicking, and striking. The students 2nd with Mr. Jason Lutman will then use these skills to participate into lead up games for sports such as football, baseball/softball, kickball, soccer, and volleyball. MEETS IN GYM Club Minimum: 15, Maximum: 30 Are you crafty and creative? Come join us as we have a Pinterest Party every PINTEREST PARTY week! During each class session, we will create a cool craft project found on 2nd with Mrs. Ginger Walley Pinterest. Participants will have input on which particular projects they would 3rd like to create. Meets in CLASSROOM #12 Club Maximum: 15 4th *Additional SUPPLY FEE of $15 required.* 5th Bashful bookworms! Raucous readers! Voracious verbalists! COME ONE, COME WORD NERDS ALL! In this enrichment class, we will combine our love of reading with 4th with Kathy Goodhart preparation for the National WordMasters Analogy Challenge. Each class will be 5th and Jennifer Ashford divided between a book club discussion and an exploration of new vocabulary words. During the last class, the students will take part in a National WordMasters Meet, consisting of 20 analogies. Students will have the option to participate in two additional WordMasters tests in February and April. Our 2-3 book club books will be determined based on enrollment and availability, but will be age-appropriate and discussion-worthy. Meets in CLASSROOM #7 Club Maximum: 12 *Additional supply fee: $10 to cover cost of WordMasters program and books. This unique and fun 6-session character development program will benefit your USTMA TAEKWONDO child at home, at school, and in team activities and sports. The program blends 1st Rise Up Kids Program martial arts with the life skill lessons such as concentration, listening skills, 2nd with Master John Choi cooperation, respect, and courtesy. The program is taught by a certified Black 3rd Belt instructor and master from the United States Taekwondo Martial Arts 4th **Please make your Academy (USTMA). Class 1 Focus, Class 2 Cooperation, Class 3 Self-Control, Class 5th check out to USTMA 4 Respect, Class 5 Discipline, Class 6 Confidence! A White Belt Graduation ceremony will be scheduled from Nov 21-24 at USTMA headquarters located at 9 Cardinal Park Drive in Leesburg, so you may see your child demonstrate the

Tienen algunas preguntas sobre esta información? Por favor llamen al 571-252-2900 y pregunten por Magaly Fagan. Muchas Gracias! After School Enrichment Program, Fall 2017

power of focus through Taekwondo! Meets on the GYM STAGE Club Minimum: 10, Maximum: 15

Scholarship Application Deadline is 3:00 pm, Monday, October 2

Some of the classes may offer a scholarship opportunity to attend a Fall 2017 After School Enrichment Program (ASEP) club. All scholarship requests will be collected and placed into a box to be randomly selected by Mr. Pellegrino. Due to the limited amount of scholarships available, please only apply if participating truly poses a financial burden to your family. Only applications submitted by the deadline will be considered. Please complete one scholarship application per student, and return it to your child’s teacher. Please note that you can apply for a scholarship in one of the below clubs assuming your student meets the grade level requirements.

Fall ASEP clubs run on Tuesdays for six weeks starting on Tuesday, October 10th. Students will need to be picked up when the ASEP program ends promptly at 3:45 p.m., or join CASA (if they are enrolled in CASA).

The following ASEP clubs are being offered this session. The PTA grants 1 scholarship per student based on need. Please indicate which club you are interesting in having your student apply for a scholarship by placing an “ X ” in the “applying for scholarship column.” You will be notified of receipt of your application and if you have been granted a scholarship for your student to attend the requested club.

Club Name Eligible Grades Applying for Scholarship?

Intro to Sports Club 1st, 2nd Sports Mix Club 3rd, 4th, 5th Pinterest Craft Club 2nd, 3rd, 4th, 5th Word Nerd Book Blub 4th, 5th USTMA Taekwondo 1st, 2nd, 3rd, 4th, 5th

CHILD’S NAME:______GRADE:______Child’s Homeroom Teacher:______

Parent/Guardian Name(s): ______

Phone #s (Cellular):______

Phone #s (Home):______

E-mails:______Tienen algunas preguntas sobre esta información? Por favor llamen al 571-252-2900 y pregunten por Magaly Fagan. Muchas Gracias! After School Enrichment Program, Fall 2017

Parent Signature: ______Date: ______Emergency Information Form

Participant’s Name: ______Last First

Parent/Guardian Name: ______

Email: ______Participant’s address: ______

Home Phone______Cell Phone(s)______

*Below list person(s) other than you who may pick your child up.

In case of emergency, please call: ______Phone number(s) ______Relationship to participant: ______Participant Medical/Insurance Data: Family Doctor: ______Phone: ______Any Allergies: ______Name of Insurance Company providing medical coverage: ______Policy# ______Permission Form/Agreement to Participate:

I am the parent/guardian of (student’s printed name) ______and give permission for my child to participate in the ASEP program. I understand that there may be risks of injury involved in the activity and the student agrees to abide by the rules of and directions of participation. I understand that Evergreen Mill Elementary PTA and Loudoun County Public Schools do not provide medical or accident insurance for student participants in PTA/School activities. I also give permission for my child to receive medical treatment, first aid, emergency medical care and all other medical care deemed reasonably necessary to their health and well-being in case of accident, injury, or

Tienen algunas preguntas sobre esta información? Por favor llamen al 571-252-2900 y pregunten por Magaly Fagan. Muchas Gracias! After School Enrichment Program, Fall 2017 serious illness during participation in the designated ASEP classes and understand that I, or my insurance, will be responsible on a primary basis for any medical bills incurred.

______(Parent/Guardian Signature) (Date)

Tienen algunas preguntas sobre esta información? Por favor llamen al 571-252-2900 y pregunten por Magaly Fagan. Muchas Gracias!