Change Language
English
español
2022-2023 LINK Club Enrollment Form
Please fill in the information below
LINK Club Site Location:*
Choose One
George Washington Middle School
Francis C. Hammond Middle School
Brent Place
Cora Kelly
Ferdinand T. Day
John Adams
Patrick Henry
William Ramsay
Community Lodgings
Jefferson Houston
Student's Current School:*
Choose One
Charles Barrett Elementary School
Cora Kelly School for Math, Science and Technology
Douglas MacArthur Elementary School
Ferdinand T. Day Elementary School
George Mason Elementary School
James K. Polk Elementary School
John Adams Elementary School
Lyles-Crouch Traditional Academy
Mount Vernon Community School
Naomi L. Brooks Elementary School
Samuel W. Tucker Elementary School
William Ramsay Elementary School
Patrick Henry K-8 School
Jefferson-Houston PreK-8 IB School
George Washington Middle School
Francis C. Hammond Middle School
Alexandria City High School
Student's Current Grade:*
Choose One
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Student Information
Student's Last Name:*
Student's First Name:*
Street Address *
Unit # (If Applicable)
City: *
State:*
Zip Code:*
Gender:*
Choose One
Female
Male
Non-binary
Date of Birth (DD/MM/YYYY):*
Is student new to LINK Club or returning?*
Choose One
New Student
Returning Student
Not Sure
Please indicate below how your child will get home following dismissal from LINK Club:*
Choose One
Parent/Authorized Person Pick up
Walk Home
Please indicate below how your child will get home following dismissal from LINK Club:*
Choose One
Parent/Authorized Person Pick up
Walk Home
ACPS Bus Transportation
Contact 1 Information
Contact 1 Last Name:*
Contact 1 First Name:*
Contact 1 Cell Phone #:
Contact 1 Alternative Phone #:
Contact 1 Email Address:*
Contact 1 Relationship to the Student:*
Choose One
Parent/Guardian
Step Parent
Aunt/Uncle
Grandparent
Sibling
Friend
Other
If you chose "Other", please describe your relationship to the student:
Contact 1 is authorized to pick up student from LINK Club:*
Choose One
Yes
No
Contact 1 is an emergency contact for the student:*
Choose One
Yes
No
Contact 2 Information
Contact 2 Last Name:*
Contact 2 First Name:*
Contact 2 Cell Phone #:
Contact 2 Alternative Phone #:
Contact 2 Email Address:*
Contact 2 Relationship To The Student:*
Choose One
Parent/Guardian
Step Parent
Aunt/Uncle
Grandparent
Sibling
Friend
Other
If you chose "Other", please describe your relationship to the student:
Contact 2 is authorized to pick up student from LINK Club:*
Choose One
Yes
No
Contact 2 is an emergency contact for the student:*
Choose One
Yes
No
Health and Insurance Information
Does your child have a medical condition that we need to be aware of, such as allergies or intolerance to foods/medicines:*
Choose One
No
Yes
If you answered "yes" above, please describe the medical condition. For any allergies or intolerance to food or medicines, please provide that information/list:
Please describe action to be taken in an emergency:*
Has your child had any recent operations or other pertinent medical experiences that may require special attention:*
Choose One
No
Yes
If yes, please explain:
Please list any prescribed medications that your child takes and what the medications are for (if applicable). While staff are not authorized to administer medicine during program hours, this information may be used in a medical emergency requiring treatment:
Please list any social, cognitive or behavioral challenges your child may have that you believe staff should be aware of:
Does your child have health insurance:*
Choose One
Yes
No
Insurance Provider:*
Policy Number:*
Child's Physician:*
Phone Number: *
Consent Agreements
Program Supervision: I understand that LINK Club is an ACPS program implemented in partnership with Department of Recreation, Parks and Cultural Activities (RPCA). RPCA will provide wrap-around supervised programming Monday through Friday for LINK Club participants. I understand that my child will be under the supervision of RPCA staff when he/she is not participating in homework help/tutoring with ACPS teachers.*
Draw
Type
Upload
Choose your signature image
Program Supervision: I understand that LINK Club is an ACPS program implemented in partnership with the Alexandria Redevelopment Housing Authority (ARHA) . ARHA will provide wrap-around supervised programming Monday through Friday for LINK Club participants. I understand that my child will be under the supervision of ARHA staff when he/she is not participating in homework help/tutoring with ACPS teachers.*
Draw
Type
Upload
Choose your signature image
Program Supervision: I understand that LINK Club is an ACPS program implemented in partnership with Community Lodgings. Community Lodgings will provide wrap-around supervised programming Monday through Friday for LINK Club participants. I understand that my child will be under the supervision of Community Lodgings staff when he/she is not participating in homework help/tutoring with ACPS teachers.*
Draw
Type
Upload
Choose your signature image
Academic Support: I understand that during LINK Club, ACPS teachers will provide my child with academic support and homework help. Though reasonable efforts will be made, LINK Club staff is not responsible for ensuring that all homework is complete and correct. *
Draw
Type
Upload
Choose your signature image
Enrichment Services: I understand that students will be engaged in a variety of enrichment clubs that support academic learning and physical, social and emotional development during LINK Club. *
Draw
Type
Upload
Choose your signature image
Emergency Medical Consent: I understand in the event of an emergency I give LINK Club consent to transfer my child’s health record to the health provider. In the event of an emergency, transportation by any necessary means to obtain medical care or assistance for my child, as circumstance may require in the discretion of LINK Club staff, its employees or agents, is hereby authorized. I further give consent to any rescue squad or emergency personnel to render transportation and/or medical care deemed necessary in their discretion and in the best interest of the life, health and well-being of my child. *
Draw
Type
Upload
Choose your signature image
I give consent and understand the LINK Club staff will be provided the Emergency Medical Information for the safety of my child. *
Draw
Type
Upload
Choose your signature image
First Aid Consent: I understand in the event of a minor accident or sudden illness my child will be treated on the premise of LINK Club by staff with emergency standard first aid procedures, as deemed necessary, for the well-being of my child. I understand I will be notified immediately and I, or an authorized person, will pick-up my child from the LINK Club. *
Draw
Type
Upload
Choose your signature image
Photo/Video Release: I understand my child may be photographed while participating in the LINK Club program. I give permission to use the pictures/videos of my child for the promotional and marketing materials such as newsletters, local newspaper, website, social media, brochures, etc. *
Draw
Type
Upload
Choose your signature image
Student Attendance: I understand that my child was selected for this program because of his/her need for additional academic support and that attendance is essential. I understand that my child is expected to attend LINK Club daily. I understand that if my child does not attend daily, s/he may lose their place in the program. If my child needs to be absent, I will contact the LINK Club Site Coordinator.*
Draw
Type
Upload
Choose your signature image
Family Participation: I understand that family engagement is important to student success and as a parent/guardian of a child participating in LINK Club, the expectation is to attend the required LINK Club Orientation and at least two additional family engagement events either in person or virtually during the school year. *
Draw
Type
Upload
Choose your signature image
I have completed this application accurately and I understand that misinformation can result in immediate dismissal from the LINK Club program.*
Draw
Type
Upload
Choose your signature image
Current Date:*
/
/
Your form has been saved. You can complete it via this link within 60 days.
Copy
Submit