Contact 1 — Hayward South County NAACP

Winton Middle School Program Enrollment Form

CONFIDENTIALITY OF INFORMATION

Please complete this form to give consent for your student to participate in the FREE after school Academic Enrichment Program sponsored by the Hayward-South Alameda County Branch of the NAACP and Reality Mentor Inc., in partnership with the Hayward Unified School District and Winton Middle School. The private information on this form shall remain confidential. The only information that will be shared with the Hayward Unified School District with respect to this program is your child's date(s) of attendance and participation in the program.

STUDENT INFORMATION

Consent and Permission is granted for:

(Student's Name)

First Name

Last Name

to participate in the NAACP/REALITY MENTOR free after school Academic Enrichment Program.

Parent(s) will be responsible for supplying the student’s electronic device needed to access the student’s daily homework assignments. Instructional services will be given at the Winton Middle School Library as follows: Tuesdays: 11:18 am – 11:48 am 11:22 am – 12:17 pm Thursdays: 11:52 am – 12:47 pm 12:17 pm – 12:47 pm

Student's Date of Birth

YYYY

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone/Cell Number

(###)

###

####

Emergency Contact

Name and Phone Number

ACADEMIC SUBJECTS

Special Concerns

Grade

Subject(s)

Math

English

Science

History

May the student share his/her online homework screen during the tutorial session?

Yes

AUTHORIZATION

By checking the box below, I hereby authorize the Hayward Unified School District to release limited academic information about my child to the NAACP | Reality Mentor Tutorial Program, such as my child's classroom assignments, grade point average, attendance and incidents of student discipline. I further authorize the NAACP | Reality Mentor Tutorial Program to release limited information about my child to the Hayward Unified School District, such as my child's attendance in this program and the subjects in which my child receives tutorial.

Winton Middle School Program Enrollment Form

Hayward South Alameda County NAACP