Vaughn Next Century Learning CenterAdmin2024-05-09T22:26:33-07:00 Next Century Learning Center College and Career ✓SAT Prep ✓Career Exploration ✓Job Resume ✓Mock Interviews ✓Financial Literacy Guest Speakers ✓College Essay Assistance ✓Scholarship and Grant Application Assistance ✓Choosing a College College and Campus Tours Vaughn Next Century Learning Center "*" indicates required fields You may register up to 2 students on this form.*# students?Please enter a number from 1 to 2.What is your preferred language? Hi! How did you hear about us? Student Name* First Name / Nombre Last Name / Apellido Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Grade* Gender* Male Female Other Allergies, Medications, Physical or Mental Limitations*Please describe any allergies (nut, foods, dust etc); and any medications the child takes. Please also describe any activities your child may not participate in, and anything else we need to know to serve your child. STUDENT 2Student 2 Name* First Name Last Name Student 2 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student 2 Gender* M F Other Student 2 Grade* Student 2 Allergies, Medications, Physical or Mental Limitations*Please describe any allergies (nut, foods, dust etc); and any medications the child takes, and anything else we need to know to serve your child. Contact and Emergency InformationParent or Guardian Name* First Name Last Name Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is there a second parent/guardian? First Name Last Name PhoneEmail In Case of Emergency Please Contact:* Emergency Contact's Relationship* Emergency Contact Phone*Additional Adult who is authorized to pick up your student(s)?(if applicable) Full Name, relationship Another Adult authorized to pick up your student(s)?(if applicable) Full Name, relationship Would you like to be part of our monthly parent support workshops ?* Yes No HiddenDo you need help with transporting child/children from school to our Otsego Street location? If no, skip this section!We have limited seats and routes available, for the Main Site (H4H on Otsego Street) only. Transportation is not guaranteed, and we will let you know ASAP if we are able to assist. You will still need to pick up your child at the end of the H4HLA program. Cost is $5 per week in advance, and payable via paypal/creditcard checkout online, or in cash in person. HiddenStudent 1 requests transportation on these days: Monday Tuesday Wednesday Thursday Select AllHiddenStudent 2 above on these days: Monday Tuesday Wednesday Thursday Select AllDemographicsThank you SO much, in advance, for completing these next questions. Hands4HopeLA receives grants that require we provide statistics, using only combined and anonymous results of these survey questions. Your responses help decide what kinds of programs and assistance are offered and funded. Annual Income in your household* Less than 40k 41k - 50k 51k - 60k More than 60k Do you need any assistance with the following:* No assistance requested Groceries Utility payments Clothing Housing Other Financial Assistance Does your family participate in any of the following programs? CalWORKs, Calfresh, Kin-GAP, FDPIR, WIA.* Yes No Does student qualify for free or reduced lunch?* Yes No Are you a Veteran?* Yes No What sex were you assigned at birth?* Female Male Decline to Answer How do you identify your gender?*M, F, Non-Binary...other...or Decline to Answer How do you describe your sexual orientation?* Do you have any disabilities?* No disabilities Chronic health condition Hearing difficulties Mental disability Physical disability Visual difficulties Other Decline to Answer How do you describe your Ethnicity?* Is there anything else we should know?Hands4Hope LA Afterschool Program Release Agreement & Waiver of LiabilityIn consideration of the services of Hands for Hope (Hands4Hope LA) and all other related entities, partners, agents, directors, advisors, officers, employees, representatives, volunteers, and all other persons acting on behalf of these entities(hereinafter collectively "Hands4Hope LA"), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge Hands4Hope LA and its representatives on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate from any and all claims, any and all auses of action that I (we) have or may have, whether past, present or future, Whether known or unknown, whether anticipated or unanticipated, as detailed in the consent boxes below. Academic Evaluation - applies to children under 18 yrs of age*I hereby give permission for the school to release any and all confidential school records to (Hands4Hope LA) for purposes of assessment and evaluation for the betterment of my child’s academic and social success and the effectiveness of Hands4Hope LA after school program. I also hereby give permission for my child to participate in activities or surveys designed to evaluate the effectiveness of Hands4Hope LA. I have read and agree.Physical Activities*I am voluntarily participating / allowing my child to participate in instruction covering a number of topics. I recognize this may include fitness or dance classes may require physical exertion hat may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician for my child (or myself if a TAY student over 18) prior to and regarding participation in dance or fitness related instruction. I warrant that if I am aware of any medical condition that my child has that would affect participation, I will fully disclose this information to Hands4Hope LA staff in writing. I have read and agree.Assumption of Risk*I understand that there is an assumed risk of injury in all (Hands4Hope LA) activities. I have read and understood this agreement, and I hereby waive all claims against Hands4Hope LA and their contractual partners for injury or damage to any person or property on and off campus premises by or from any cause whatsoever including the after school program’s negligence. I agree to hold Hands4Hope LA and their contractual partners free from any liability or responsibility for damages arising from any injuries to myself, my child, my children, or property owned by any of us. I have read and agree.Release of Information* I grant permission to Hands4Hope LA, its agents and assigns, to use my child’s name, demographic information, program outcomes, service assessments, services information for the purposes of grant reporting to Los Angeles County and other funding agencies. Hands4Hope LA is funded by several grants from various organizations and it is necessary to share basic information about program participants in order to receive funding. I have read and agree.Media Release*I hereby grant permission to Hands4Hope LA, its agents and assigns, to use child’s photo or video, and likeness for the purpose of romotion by Hands4Hope LA for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website, marketing, advertising, trade, promotion, exhibition for an indefinite period of time. I further acknowledge that I will not be compensated for these uses and Hands4Hope LA owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release Hands4Hope LA and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights ofpublicity or copyright. I have read and agree.Signature of Parent/Guardian* I have read the above agreement and understand fully the terms and conditions that have been explained. By signing this release agreement & waiver of liability form I am giving my child permission to attend Hands4Hope LA academic after school program.ReCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Share with your Friends and Colleagues! FacebookXRedditLinkedInWhatsAppTumblrPinterest
