2018-2019 Summer Student Application 

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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 2019 Summer for The Neighborhood Tutoring Program.

Please visit this page for more information regarding the Neighborhood Tutoring Program. 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 received a completed application
  • Your student must attend a testing session so that we can determine their eligibility for the program (you will be invited to schedule a testing session date after your application is reviewed)

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:

Diana Romero                                  MAIL:                                          SCAN & E-MAIL:           FAX:

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

Phone: (202) 349-3517                   Washington, DC 20003 

Yes

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2019 Summer Neighborhood Tutoring Program

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STUDENT INFORMATION

STUDENT EDUCATION INFORMATION
Does your student have any of the following plans to receive supplemental services or accommodations at school?
FLOC INVOLVEMENT

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PARENT / GUARDIAN INFORMATION #1
SECONDARY CONTACT INFORMATION( NOT REQUIRED)
This secondary contact can be additional parent/guardian, relative, neighbor,etc.
EMERGENCY CONTACT INFORMATION (Required - must be someone other than parent / guardian)  
STUDENT'S FAMILY BACKGROUND AND HOUSEHOLD INFORMATION
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 2016, please provide the best estimate of your household income, including TANF, SDI / Social Security, retirement, child support, alimony, etc. 
Number of people
How many people live in the student's primary household?

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MEDICAL HISTORY
MEDICAL FORM
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).

RELEASE FORM

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.

FERPA CONSENT FORM

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

FERPA Participant Consent Form 
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, 2018 – July 31, 2019.

 

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.                                                                        

OST OFFICE CONSENT

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.

SIGNATURE
  • 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.)


Contact Information