Team Prime Time Webster Middle School

Academics • Enrichment • Sports & Recreation FREE EVERY DAY AFTER SCHOOL

Limited to first 100 students

Open to all 6th, 7th& 8th graders Monday – Friday from dismissal until 6 pm Professional staff at a 20:1 ratio

Includes daily meal

To enroll, complete the application and return to

Team Prime Time via mail, email, or fax

Team Prime Time P.O. Box 241496

Los Angeles, CA 90024 (310) 838-7872

www.teamprimetime.org (310) 838-8825 fax

info@teamprimetime.org

ACADEMICS

Homework assistance offered every day

Literacy Programs including Poetry Clubs and Creative Writing

S.T.E.M. projects Science, Technology, Engineering and Math based enrichment

ENRICHMENT

Visual Arts – painting, drawing, sculpting

Dance – drill and cheer

Media Arts – photography and film

Music – music production and DJ classes

SPORTS & RECREATION

LA84 Sports League – basketball, soccer, football, volleyball, softball

Competitive Tournaments

Health and Fitness Program

Boys and Girls Teams

Other group games and sports offered every day

Enrollment 2015-2016

Los Angeles Unified School District BEYOND THE BELL BRANCHBEFORE AND AFTER-SCHOOL PROGRAM APPLICATION/AGREEMENT

For Staff Use Only

DISTRICT ID NUMBER ______________SCHOOL YEAR

Form BASPA/A 072514

SCHOOL OF ATTENDANCE: _____________________________Program Applying for: (Only check one)

BEFORE-SCHOOL AFTER-SCHOOL OTHER PROGRAMS

Ready-Set-Go! (RSG) Youth Services Grant Funded Program (ASES/21st CCLC/ASSETs)

Name of Program __________________________________

Name of Program

_________________________________________

� � � � APPLICANT(S)

PRINT NAME CLEARLY FIRST M.I. LAST APPLICANT’S EMAIL ADDRESS DATE OF BIRTH GRADE

STREET ADDRESS APT # CITY ZIP CODE

PARENT(S)/GUARDIAN(S)

EMERGENCY CONTACT/RELEASE INFORMATION (provide a minimum of two contacts)

#1: RELATIONSHIP NAME (FIRST LAST) PHONE NUMBER(S) ADDRESS (STREET CITY ZIP)

#2: RELATIONSHIP NAME (FIRST LAST) PHONE NUMBER(S) ADDRESS (STREET CITY ZIP)

#3: RELATIONSHIP NAME (FIRST LAST) PHONE NUMBER(S) ADDRESS (STREET CITY ZIP)

I/We authorize the Beyond the Bell Before/After-School Program (BASP) to contact, and if necessary, release my child to any of the above individuals listed as an Emergency Contact/Release Information. The above listed individuals must be 18 years or older.

I/We give my permission for my child to be filmed or photographed. I understand that all film or photos are the sole property of the BASP, and may be used in displays to the public, to publicize the program, or for printed materials published by and/or for the BASP.

I/We hereby consent to the disclosure of personally identifiable information from my child’s education records under the Family Educational Rights and Privacy Act and allow for the Los Angeles Unified School District to disclose such information only to the extent and for the duration necessary for my child to participate in BASP programs. Does your child have any physical, emotional, and/or learning difficulties? If so, please specify: _____________________________________________________

_______________________________________________________________________________________________________________________________________

Does your child have any food allergies? If so, please specify: __________________________________________________________________________________

ACKNOWLEDGEMENT

MOTHER’S/GUARDIAN’S NAME (PRINT) MOTHER’S/GUARDIAN’S SIGNATURE DATE

FATHER’S/GUARDIAN’S NAME (PRINT) FATHER’S/GUARDIAN’S SIGNATURE DATE

SITE COORDINATOR’S NAME (PRINT) SITE COORDINATOR’S SIGNATURE DATE

MOTHER’S/GUARDIAN’S NAME FATHER’S/GUARDIAN’S NAME

PRINT NAME: FIRST M.I. LAST PRINT NAME: FIRST M.I. LAST

MOTHER’S/GUARDIAN’S EMAIL ADDRESS FATHER’S/GUARDIAN’S EMAIL ADDRESS

PHONE NUMBER (MAIN) PHONE NUMBER (OTHER) PHONE NUMBER (MAIN) PHONE NUMBER (OTHER)

TEAM PRIME TIME Webster Middle School 2015-16 Additional Information

Date Received: __________

* EMERGENCY INFORMATION *Doctor’s name: Phone: ( )

Medical Insurance Co.: Policy #:

Does your child(ren) have any physical activity restrictions? ___YES ___NO

Does your child(ren) have any allergies to any foods or medications? ___YES ___NO

Does your child(ren) have any dietary restrictions? ___YES ___NO

If YES to any of the above, a Medical Information and Clearance Form will be sent to you to complete before your child can begin the program.

Will your child be required to take any medication while at Team Prime Time? ___YES ___NO

If YES, a Prescription/Non-Prescription Medication Dispensing Agreement will be sent to you to complete before your child can begin the program.

Is your child currently supported with additional adult assistance? ___YES ___NO

If YES, the Adult Assistance Information Form will be sent to you to complete before the Adult can begin providing services.

1. In case of an emergency and I cannot be reached, I authorize the Team Prime Time Director, or his designee, to obtain whatever medical treatment he orshe deems necessary for the welfare of my child. I understand the potential risks involved in the activities provided by Team Prime Time and I hereby agreeto assume all such risks, including the risk of injury to my child. I hereby release, and agree to protect, defend, indemnify and hold harmless Team PrimeTime, Inc. and its owners, directors and staff from any and all claims arising out of injury to my child. I also agree to accept full responsibility, financial orotherwise, for the conduct of my child. I further understand that my child may be dismissed from the program for conduct deemed improper by the Directorin his sole discretion.

2. I understand that all children participating in the program will sign themselves in and out. I understand and agree that Team Prime Time is not responsiblefor my child before he or she signs in or after he or she signs out of the program. I understand that it is my sole responsibility to arrange for signing my childin and out of the program and for arranging for his/her drop off and pick up. I understand and agree that Team Prime Time is not responsible for my child orfor the actions and behavior of my child in the event that my child leaves the supervision of the program during the hours of the program, regardless ofwhether or not he or she has signed out.

3. All pictures, films, tapes, or other likenesses of my child taken during Team Prime Time are the property of Team Prime Time and may be used for any andall promotional materials.

4. I understand, authorize, and agree that any art projects made by my child during, or as part of, the Team Prime Time Art Academy (or any likenesses,replicas, or re-creations of any such art projects made by my child) may be used, depicted, or displayed by Team Prime Time for any promotional orfundraising purposes that Team Prime Time may choose or deem appropriate.

5. I understand that all District-sponsored programs, as well as, all nonprofit and for profit organizations and agencies’ programs operated on District propertymust comply with Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act of 1990, Title VI of the Civil Rights Act of 1964and Title IX of the Education Amendments of 1972, as well as all other federal and state laws prohibiting discrimination against individuals based on thefollowing protected categories: age, disability (mental or physical disability or reasonable accommodation); sex (including sexual orientation or genderidentity, pregnancy, childbirth or related medical condition); or any other basis protected by federal, state, local law, ordinance, or regulation.

6. As it pertains to the LAUSD Beyond The Bell Branch’s Afterschool Outcome Measures Online Toolbox:

a. I give consent for my child to participate in activities/surveys designed to evaluate the effectiveness of the Team Prime Time After School Program.

Yes ____ No ____

b. I give consent for the program staff/evaluation team to access my child’s current and past records such as achievement scores, grades, attendance, etc.

Yes ____ No ____

I have read the above conditions, understand them and agree to comply:

_________________________________________________ _______________________Signature of Parent or Guardian Date

TEAM PRIME TIME FREE to Webster students – Monday-Friday from dismissal until 6:00pm

(310) 838-8825 fax info@teamprimetime.org P.O. Box 241496 Los Angeles, CA 90024

8/7/15