Jennings Community Learning Center - 2455 University Ave. W. - St. Paul, MN 55114

REGISTRATION FORM

ALL SPACES MUST BE FILLED IN

Today’s Date ______________________ Start Date (To be completed by staff) ________

Student’s Full Name_______________________________________________ Grade entering__________

Male___ Female____ Birthdate _________________ Student’s Social Security No.___________________

Parent /Guardian Information

Name _______________________Relationship to student __________E-Mail Address

Home Address ____________________________________ City _____________________ Zip ___________

Pager/

Home Phone _____________________ Work Phone ___________________ Cell Phone________________

Is this Student’s residence? Should school mailings be sent to this parent/guardian?

Name _______________________Relationship to student __________E-Mail Address

Home Address ____________________________________ City ______________________Zip___________

Home Phone _____________________ Work Phone ___________________ Cell Phone________________

Is this Student’s residence? Should school mailings be sent to this parent/guardian?

Name of Previous Schools Attended – please include all high schools and last middle school.

School Name School Address School Phone Dates Attended

Student’s Full Name

**Emergency Contact Information**

Please list the names of other individuals that we may contact in an emergency in the event that we are unable to reach you.

Name _______________________________________________ Relationship to student _____________

Address ________________________________________ City ______________________ Zip___________

Pager/

Home Phone _____________________ Work Phone ___________________ Cell Phone _______________

Name _________________________________________ Relationship to student _______

Address ________________________________________ City ______________________ Zip __________

Pager/

Home Phone _____________________ Work Phone ___________________ Cell Phone _______________

Are there any other people we may find helpful to contact while working with your student? (social worker, mentor, etc.)

Name Name

Phone Phone

**Medical Information**

Does your student have any allergies, special health concerns, or medications that we should be aware of?

(if student has medications, the Authorization to Administer Medication form must be filled out.)

_______________________________________________________________________________________

Doctor’s Name ________________________________________ Phone number ______________________

Complete Clinic address

_____________________________________________________________________________

Does your student have health insurance? Name of Insurance Company

Group # Member #

What hospital do you use?

Student’s Full Name

*Has this student ever received special education services (IEP) or does your student currently have a section 504 educational plan? ______yes no not sure

TIP

Has your student ever been involved with TIP or the Truancy Intervention Program?

Does your student have a PO? Name Phone #

Child’s racial/ethnic group:

 Native American/Alaskan  Caucasian  African American  Hispanic  Asian  Somali

(If Asian, please select one below):

 Pacific Islander  Hmong  Vietnamese  Cambodian  Laotian  Other _______________

Student language information:

Which language did your child learn first?

Which language is most often spoken in your home?

Which language does your child usually speak?

**Optional Additional Information**

Are there any special concerns that we should know about?

Jennings Community Learning Center does not discriminate because of sex, creed, color, religion, national origin, disability, marital status, status with regard to public assistance, sexual orientation or any other protected class status defined by local, state or federal law.

School Permissions

Student’s Full Name Date

Parent/Guardian Full Name

Medical Emergency/Liability Waiver

I hereby give my permission for Jennings Community Leaning Center staff members to procure all necessary medical help for my child or ward while this person is under the supervision of the Jennings Community Learning Center educators and grant permission to its representatives to authorize any competent medical person to do all things reasonably necessary to take care of any injury or sickness. There is no health insurance or medical coverage provided. The signing of this form acknowledges that the student’s parent/guardian accepts responsibility for payment of any medical treatment, which may be required while he or she is in this program.

Parent/Guardian please initial: Yes No

Study Trips

Study trips are an important part of the Jennings Community Learning Center experience. Your signature authorizes your student to attend study trips that are developed as part of the school program.

Yes_________ No_________

Does your son or daughter have any special health problems or handicapping conditions which will require special attention or supervision on study trips?

Yes No

If yes, what is the condition and what special considerations should be made?

I understand that the necessary arrangements, plans, and precautions will be taken for the care and supervision of students during the trip. Beyond this, I will not hold the school liable for accidents occurring on the trip.

Parent/Guardian please initial: I will not hold school liable/ I will hold the school liable

PLP Off Site Learning

The Jennings Community Learning Center encourages students to develop personal learning plans and projects which sometimes require them to go off site to internships, research locations, carry an Excuse to Leave the Building pass with them and to sign out on a school calendar or with a teacher noting community service projects or other learning experiences somewhere other than the school site. The students will be require

d to their location, contact person and phone number of the location. Your signature authorizes your student to participate in these off site learning experiences.

Parent/Guardian please initial: Yes No

Student’s Full Name Date

Guardian Full Name

Media Release

I hereby grant the Jennings Community Learning Center the right and permission to use my son’s or daughter’s name and reproduction of physical likeness for the purpose of publicizing the program through pamphlets, video, newspaper, periodicals, etc.

Parent/Guardian please initial: Yes No

Video/Sound Permission

At Jennings, we often produce various types of videos and sound recordings. Some of these recordings will be used on St. Paul Neighborhood Network (SPNN) or St. Paul cable channels. Some of the sound recording and video clips may be broadcast on radio or on our web site. It is important to us that you agree, and are comfortable with, public broadcasting of video or sound productions that include your student.

I give my permission for to have school related sound or video

Student’s name

productions publicly broadcast.

Parent/Guardian please initial: Yes No

Publishing of student work on the World Wide Web

We understand that some of our student’s work may be published on the WWW or communicated with others via electronic mail. This may include produced web pages, photographs of student, artwork, writing, electronic presentations, etc.

We further understand that the work will appear with a copyright notice prohibiting the copying of such work without express written permission. In the event that anyone requests such permission, those requests will be forwarded to us as parents/guardians. No home address or phone numbers will appear with the work.

We grant permission for the World Wide Web publishing as described above.

Parent/Guardian please initial: Yes No

Rights and Responsibilities

We have reviewed the student’s Rights and Responsibilities book. We have read and understood the overview of the School Board Policies. Copies of individual policies are available at Jennings Commuity Learning Center and are available by parent or student request.

Parent/Guardian please initial: Yes No

Open Lunch Program

No open lunches will be allowed without this permission form being read and signed by student and parents.

OPEN LUNCH GUIDELINES

1. I give permission for my student to leave school grounds during the daily lunch period.
2. The school district is not responsible for supervising the student during the lunch period if they leave campus.
3. The school district is not responsible for determining the manner in which the student leaves campus, whom he/she leaves campus with, or what he/she does during the period of time he/she is off campus.
4. The school district retains the right to discipline the student for failing to return to school at the appropriate time after the lunch period ends.
5. The school district will not be held liable for any injury or any other type of damages sustained by the student during any period of time that the student is off campus during the lunch period, or any injury or other damage sustained in leaving or returning to school grounds.

 I agree and will abide by all rules and conditions stated above.

Student Signature____________________________________ Date______________________

I give permission for my son/daughter to participate in open lunch.

Parent Signature_____________________________________ Date______________________