Student Application - The Clearport

Name*

First Last

Date of Birth*

School*

Grade*

Student's Email*

Student's Cell*

Parent Portal Username ( optional, but student needs to be able to keep track of grades)

Password

Parent or Guardian Name(s)*

Address

Street Address

Home Phone #*

Mother’s cell or gaurdian #*

Father’s cell or other gaurdian #*

Parent or guardian’s Email*

EMERGENCY CONTACTS

Name

Relationship

Phone #

Student Lives With:

Father

Mother

Step Parents

Foster

Legal Guardian

Primary Language

English

Spanish

Other

Does The Clearport Learning Center Program have permission to use photos or videos of your child in educational or promotional materials? (There is no cost.)*

Yes

Parents of Athletes: I give permission for Clearport to communicate and update coaches about my child's academics.*

Yes

N/A

I hereby release, absolve, indemnify and agree to hold harmless the individuals, organization and facilities, The Clearport Learning Center from any claim, demand, or action rising out of, or in any way related to The Clearport Learning Center or related activities, including but not limited to any injury to my child/minor stated above.

In the event of any injury, The Clearport Learning Center staff is authorized to obtain any medical care of treatment deemed necessary. I have carefully read the above waiver and release and fully understand this is a release of liability and I sign it voluntarily.

Parent or Guardian Signature*

Date*

I give my child permission to utilize transportation provided by Clearport and/or the school system .*

Yes

I understand that The Clearport Learning Center is a FREE program. We are funded through a private grant. I give permission for The Clearport Learning Center staff to review my child’s academic files for the purposes of analyzing program effectiveness and reporting to funding sources.

Parent or Guardian Signature*

Date*

PARENT SURVEY

Does your child qualify for free or reduced lunch?*

Yes

Does your child have any learning disabilities?

Yes

If so, do they have an IEP?

Yes

Number of Members in Household*

Household Income Range*

What goals and visions do you have for your child? How can Clearport help? Is there anything we should know about your child?

Students are required to adhere to Clearport policies. Anyone refusing to do so will be removed from the program. Students are required to be respectful all times. This includes but is not limited to no foul language, no horse playing, no derogatory comments, no fighting, no stealing. Students are allowed to check in and out of The Clearport without a parent being present. We are not responsible for your child once they have left our building. However, students that do not follow their parents’ instructions will be suspended. Students are required to help with the maintenance of the facilities. This includes, but is not limited to cleaning up and taking out trash, pulling weeds, washing dishes, wiping down tables, and vacuuming. This is to teach our students responsibility and help them to take ownership in the building. I understand that the Clearport Learning Center requires a commitment to education. Students attending the center must meet academic obligations to use the facilities. Students are also required to follow the code of conduct which will be given at orientation. Your child must have access to their parent portal to review grades before attending the center.

Parent or Guardian Signature*

Student Signature

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