2019-2020 City Leaders Program Student Application 

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floc logo
Dear Parent(s) / Guardian(s):  Thank you for your interest in For Love of Children (FLOC).  FLOC provides FREE educational services beyond the classroom to help students succeed from first grade to college and career. FLOC is currently accepting applications for the 2019-2020 School Year for The City Leaders Program.

This application is for your student's participation in the City Leaders Program. Please visit this page for more information regarding the City Leaders Program and other program options that include the Neighborhood Tutoring Program and the Outdoor Education Center. You will be contacted with the next steps within two weeks of your student's application being submitted. 

Application Checklist


In order for your student to be considered for FLOC participation:

  • We must receive a completed application
  • We must receive proof of eligibility for FDPIR, TANF, SNAP, or Medicaid card. (Must provide even if the student is in FLOC programs already)

We must receive the following documents IF your student is receiving supplemental services at school:

  • Individualized Educational Plan (IEP)                      
  • Functional Behavior Assessment
  • Behavior Intervention Plan
  • 504 Plan


If you are unable to upload any of the additional documents in this form, please submit them to:

                                                            MAIL:                                          SCAN & E-MAIL:           FAX:

Recruitment & Outreach                      1301 Pennsylvania Avenue SE        rando@floc.org          (202) 462-9280

Phone: (202) 349-3514                         Washington, DC 20003 


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2019-2020 City Leaders Program  (YOU MUST PICK ONLY 1 PROGRAM PER LOCATION)
College and Career Readiness 
FLOC is committed to preparing high school seniors for their transitions out of high school, no matter what path they choose. Once a week, 11th and 12th grade students’ work with College and Career Readiness Coaches to complete the college application process, filling out and understanding FAFSA, identifying scholarship opportunities, and taking college tours. In the Spring, participants will work on career exploration, workforce development and scholarship applications.
Once a week, 9th - 12th grade students have the opportunity to work with SAT Prep tutors to strengthen their understanding of critical SAT components such as reading comprehension, data interpretation, and vocabulary. Participants will take a number of mock SAT exams to prepare for the exam proctored by College Board.

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Does your student have any of the following plans to receive supplemental services or accommodations at school?

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This secondary contact can be additional parent/guardian, relative, neighbor,etc.
EMERGENCY CONTACT INFORMATION (Required - must be someone other than parent / guardian)  
This information will be used to process a student's application and for FLOC's statistical reports to organizations that make donations to the FLOC program. All of your responses will be kept confidential.
*Please note: If you did not file taxes in 2018, please provide the best estimate of your household income, including TANF, SDI / Social Security, retirement, child support, alimony, etc. 

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I certify that the medical information provided above is accurate to the best of my knowledge. I understand that FLOC will not allow my child to take medications not listed on this form without direct consent from a parent / guardian. I understand that I am required to give medical consent in order for my child to participate in any FLOC program(s).


This form is required. This page MUST be completed and signed by the student's legal parent or guardian

Medical Authorization
I grant permission for a representative of For Love of Children to have my child treated at an appropriate facility in the case of an emergency while my child is in attendance at a For Love of Children program. I understand that representatives of For Love of Children are not medical professionals and will only seek medical assistance from a licensed medical facility in case of emergency when I cannot be reached. I waive my right to prosecute any representative from the program who proceeds as above.
Report Cards, Standardized Test Results, and Education Plans
I grant permission for a representative of For Love of Children to request and receive copies of my child’s report cards, transcript, standardized test results, and supplemental education plans (IEP, behavioral plans, etc.) from my child’s school.
Other Service Providers
I grant permission for a representative of For Love of Children to communicate with other agencies/service providers who are providing assistance to my child, including school counselors, teachers, social workers/case managers, or other non-profit agencies. I understand that FLOC will be communicating with these providers in order to better coordinate services to help my child, and that information about my child will not be shared with anyone outside of the providers, FLOC staff, me, and/or other legal parents or guardians.
Dismissal From Program
Media, Photography, and Video
I understand and give permission to For Love of Children and approved partners to use information about my student's involvement and progress in program as well as photos or video of my child for use as FLOC deems appropriate for publicity and fundraising purposes. I understand that FLOC will keep my child’s name confidential unless I give permission for use of my child’s first name for publicity purposes (or with photos or video) by answering “Yes” to the following question.
Please note: For Love of Children will contact you directly for permission if we ever wish to use your child's full name (first and last) for publicity or fundraising purposes.
I have read and understand all of the above and want my student to be considered for participation in FLOC.


This form is required. This page MUST be completed and signed by the student's legal parent or guardian

FERPA Participant Consent Form 

Education records are considered confidential documents protected by the Family Educational Rights and Privacy Act (FERPA), a federal law designed to protect the privacy of, and provide access to, student education records. FERPA gives parents, legal guardians and students age 18 and older certain rights with respect to their education records, including, but not limited to:
  • The right to inspect and review education records within 45 days
  • The right to seek to amend education records
  • The right to have some control over the disclosure of information from education records

I authorize and consent DCPS Office of the Chief of Staff and/or my child's school to provide information concerning the education of my child to For Love of Children and United Way of the National Capital Area. I further authorize the release of educational records of my child for the current school year to the parties listed above that include the following information: education transcripts, school/program enrollment information, universal student ID, attendance data, credit history, grades, assessment data, IEP information and graduation attainment (12th grade only). This authorization and release shall remain in effect from August 1, 2019 – July 31, 2020.


By signing below, 1) I acknowledge and understand that I have the opportunity to review the records to be disclosed and the right to challenge the contents of such records; and 2) I am at least 18 years of age or I am signing this document on behalf of my child because he/she is not 18 years of age. 


For Love of Children (FLOC) is funded by the Office of Out of School Time Grants and Youth Outcomes (OST Office), a D.C. Government agency through United Way of the National Capital Area. As a grantee we are required to share participant information with the OST Office that may be collected on this form.


In addition, we are required to administer a questionnaire called the Survey of Academic and Youth Outcomes (SAYO). The SAYO is a brief survey with questions about what your child thinks of the program and of the potential benefits from attending the program. All information collected through the SAYO is confidential and no individual child or their individual responses will be identified. Participation in the SAYO is voluntary. 

By signing below I give permission for my child to be included in the SAYO survey. I further authorize For Love of Children to provide name and date of birth to the OST Office.

I have read and understand all of the above and want my student to be considered for participation in FLOC.

  • I certify that the above information is accurate to the best of my knowledge.
  • I understand that my student is being considered for admission into For Love of Children program(s) and that submitting this application and attending testing does not guarantee my child a place in any FLOC program.
  • I understand that before my student will be considered for any FLOC program, I must submit all required documentation (application, report card / transcript, and any applicable supplemental education plans.)

                                                         Attendance Policy 
It is the goal of For Love of Children (FLOC) to build strong relationships with participating students and their parents so that we may serve them effectively.  In order to do this, FLOC requires that all participating students attend regularly, arrive on time, and to never leave early without consent from an appropriate FLOC staff member.


Once accepted to the program, students are expected to maintain excellent attendance.  Students may receive no more than 3 absences over the course of the school year. Students will be removed from program with 4 absences.

Students will be signed in and out daily.  Staff will document if a student is absent, tardy, or leaves early.  We also carefully record communication from parents / guardians regarding their student’s attendance. 



Parents are requested to call FLOC’s attendance line at (202) 349-3519 or email CLP@floc.org to inform staff at least 2 hours in advance of program if students are going to be absent. 
The City Leaders Program lasts from September 17th- June 16

Food Policy


FLOC agrees to provide a snack to students during the program. Outside food is not allowed in program, with the exception of a documented medical need, or dietary restriction. 


Electronics and Cell Phone Policy


Personal cell phones and electronics are not allowed in program unless requested by the parent or guardian in writing prior to the beginning of program. If you need to contact your student, please use the provided program phone numbers. Additionally, FLOC is not responsible for any damaged, broken, lost, or stolen cell phones, IPads, or any other type of electronic device. 




Drop off will not be allowed earlier than 5:45 pm. The student should arrive to program not later than 6:15 pm. Volunteers could be re-paired with another student or sent home after 6:15 pm.


Pick up will be at 8 pm.

                                                                                  DRESS CODE


Students are not to wear clothing with offensive language, or any clothing that would not be appropriate for school or work. FLOC is not responsible for any lost, damaged or stolen clothing or personal items. 

PARENT AGREEMENT (Must be filled)


As a parent / guardian, I:


1.    Confirm that I have received a copy of the FLOC Attendance Policy.  I understand that I must contact FLOC at least 1 hour prior to the start of programming.  I agree to encourage my student to have regular and punctual attendance.  I understand that repeated tardiness or excessive absences (2) will result in my student being removed from the FLOC program(s). 


2.    Confirm that I have received notice of FLOC’s policy on outside food and the electronics / cell phone policy (as outlined above), and am aware that failure to abide by this agreement may lead to the termination of my child from the FLOC Program.





I give permission for my student to participate in FLOC programs.

Appropriate Behavior at FLOC


Be Respectful.  Follow the instructions of FLOC staff and volunteers.  Respect the space and belongings of other students.   
Be Kind.  Keep your hands to yourself except to help someone.   
Be Responsible.  Always be an active participant in your FLOC program(s).  The more effort you put into your FLOC activities, the more you will learn and have fun.   
Be Considerate.  What you do impacts not only you, but those around you.  Make sure you’re helping to create a positive learning environment. 


FLOC’s No Tolerance Policy


The following behaviors will result in permanent dismissal from FLOC program(s).


      Possession or use of a weapon / weapon look-alike.

      Possession of / being under the influence of drugs, alcohol, or tobacco.  

      Physical fighting of ANY kind (including rough-housing).

      Threat or intent to harm another participant and / or staff member with an object being used as a weapon. 

      Physical or sexual harassment of another student or staff (ex:  inappropriate touching, sexual language used).

      Blatant disrespect / defiance


                                                    Parent & Student Agreement Form