Mission Learning Center (MLC) & 826 VALENCIA

Application for Summer Reading Program

(Fill out one per student)

Student’s Name______________________________________________________ Grade____________ Age _________ Sex: M[ ] F[ ]

Address ________________________________City ___________________ Zip Code _________ Home phone__________________

School ____________________________________________________ Teacher _________________________________________

Birth Date ____________ Ethnicity ___________________ Attended MLC Reading Program Before? [ ] No [ ] Yes-When?__________

How did you hear about this program? _________________________________________________________________________________

Family Statistical Information

This information is for statistical purpose only, to satisfy funding agency requirements and is kept confidential.

Please choose which RACE & ETHNICITY best describes student:

[ ] African American [ ] American Indian/Alaskan Native [ ] Arab [ ] Caucasian [ ] Chinese [ ] Filipino [ ] Japanese

[ ] Korean [ ] Latino [ ] Multi-Racial [ ] Russian [ ] Samoan [ ] Vietnamese [ ] Other

Language spoken at home: ____________________________________

Is your child or are family members in household eligible for services from: [ ] TANF [ ] JTPA [ ] Food Stamps [ ] SSI [ ] Medi-Cal

Parent/Guardian Information

Name __________________________________ Relationship ____________________Telephone ____________________________

Emergency Information - We Can Only Release Your Child To The People Listed Below

Please list the name and phone number of persons who can be contacted in case of an emergency and who are authorized to pick up your child from the program. Attach list of additional contacts if necessary.

Name __________________________________ Relationship ____________________Telephone ____________________________

In case of separation or divorce, does the non-custodial parent have permission to pick up the child? [ ] Yes [ ] No

Medical Information

Family Doctor _____________________________ Phone _____________________ Hospital________________________________

Does your child have any medical conditions (allergies, asthma, heart condition, seizures, diabetes, hearing or sight loss, etc)?

[ ] Yes [ ] No Please explain ____________________________________________________________________________

Does your child take any medication during the day?

[ ] Yes [ ] No Please explain ____________________________________________________________________________

Please Read The Following and Sign Bellow

I hereby certify that, to the best of my knowledge, the above statements are true and correct. I understand this information is subject to verification only by authorized HUD (Housing & Urban Development)/MOCD officials. I give Mission Learning Center (MLC) permission to assess my child’s reading skills with the understanding that this does not ensure placement in the program. Upon acceptance, I give my child permission to participate in MLC’s Programs. I give MLC permission to contact my child’s teacher to discuss his/her reading progress. I also give my child permission to attend field trips in MLC’s Programs. I give MLC permission for my child to be photographed, videotaped, and/or audio taped for the purposes of students’ learning and/or publicity for the program. I give permission for my child to receive emergency medical treatment if necessary. I understand that MLC cannot assume responsibility for injury or death and I agree to hold harmless MLC their directors, officers, employees, and volunteers, from any liabilities, demands, or claims for damage.

Parent/Guardian

Signature ___________________________________________________ Date ____________________________________

Additional Information or Comments:_____________________________________________________________________________

For Agency Use Only: Date Recv’d: _______________ Teacher Ref’d: [ ] Y [ ] N MOCD: [ ] Y [ ] N Circle: Wait List or Enrolled Site: ___________