826DC Student Application

First Name

Last Name

Date of Birth

School Name

Type of School

If other type of school, please specify

Does your student have any special needs (e.g., learning, physical or mental health)?

If yes, please explain:

Does your student have an Individualized Education Plan (IEP)?

If yes, please explain:

I give 826DC permission to communicate these needs to volunteers in order to support their work with my student.

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

If other, please specify

City

State

Zip Code

Yes, this is the student's primary address

Daytime Phone

Evening Phone

Cell Phone

Home Phone

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

If other, please specify

Daytime Phone

Evening Phone

Cell Phone

Home Phone

Check if address information is the same as above. Uncheck if you want to enter different address info for Parent/Guardian #2.

Yes, use the address information above

Street Address

City

State

Zip Code

Check box if this is the student's primary address

Yes, this is the student's primary address

First Name

Last Name

Relationship to Student

If other, please specify

City

State

Zip Code

Daytime Phone

Evening Phone

Cell Phone

Home Phone

First Name

Last Name

Relationship to Student

If other, please specify

City

State

Zip Code

Daytime Phone

Evening Phone

Cell Phone

Home Phone

Is your student enrolled in an English Language Learner program (ELL/ESL)?

If yes, what level has your student been assigned? (Please refer to your latest report card)	If yes, please select your student’s first language:
If other, please specify:

If yes, please explain:

My student has anaphylaxis

My student carries epinephrine (e.g. EpiPen)

If you answered yes to any of the above, please fill out the Food Allergy and Anaphylaxis form and return to 826DC.

My student has asthma

My student carries an inhaler

PLEASE NOTE:
826DC is a nonprofit organization and a chapter of the 826 National network, both of which are dedicated to supporting under-resourced students ages 6 to 18 with their creative and expository writing skills and to helping teachers inspire their students to write. For all permission and release information below, “826DC,” “we” and “us” collectively refers to 826DC and/or 826 National. The "Author" refers to the student participating in 826DC's program. This form is an agreement between the participating student if over 18 or the parent(s)/guardian(s) of the participating student if under 18 and 826DC.

A NOTE ON IN-CENTER PROGRAMS:

826DC is a writing center, where students are invited to come work on and receive assistance with homework, individual work, and writing projects when the center is open to students. Although students are encouraged to feel at home while in the center, they are also expected to have homework or writing work to do. In the center, we are collectively respectful of each other and our surroundings. 826DC staff reserve the right to ask students to leave if we feel they are being too disruptive. 826DC should not be considered an alternative to daycare services. All students must sign up for in-center programs in advance, unless the program is specifically labeled as “drop-in.” Families are responsible for making any necessary arrangements to get their student home.

Is your student 18 years or older?

Parent/Guardian First Name

Parent/Guardian Last Name

Student First Name

Student Last Name

Date Signed

SCHOOL CONTACT PERMISSION

In order to gain information about the impact of our programs and better address the needs of students, 826DC may request access to student data from their school, including (but not limited to): attendance records, grades, graduation rates, reading and writing assessment results, and standardized test scores. Consent to such communications and to 826DC’s receipt of such information is NOT required for your Student to participate in 826DC programming.

I have read all of the above information and:

PERMISSION FOR FEEDBACK

In order to gain information about the effectiveness of our programs, evaluation in the form of surveys, verbal discussions, or writing assessments may be requested by 826DC from students, parents and teachers. Participation in any of these evaluations is NOT required. No identifying information will be attached to any results that are shared outside of the 826 Network and its advisory committee and writing assessors. Anonymous findings will be shared with our existing, or potential, donors, funders, and partners for the purpose of demonstrating the effectiveness and impact of our programs.

I have read all of the above information and accept the stated terms and conditions.

PERMISSION FOR EMAIL AND MOBILE PHONE NUMBER COLLECTION AND COMMUNICATION

For purposes of communicating with students about current and upcoming program opportunities and events, 826DC and 826 National may collect email addresses and email students ages 13 and above. This information will be used solely for program, event, and alumni engagement purposes by 826 and will not be used for any commercial purpose or given to any third party. Students may opt out of these communications at any time.

I have read all of the above information and accept the stated terms and conditions.

Student Email Address

Student Mobile Phone Number