Barton's Boosters

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Student Enrollment Kit

The administration and staff of the Wayne Barton Study Center are delighted to have your child participate in our Barton’s Boosters programs. At the Study Center, your child will find comprehensive programs to help him or her achieve a higher level of success in school.

Our goals are to help students:
• Improve F.C.A.T. scores and successfully pass all F.C.A.T. tests
• Improve overall Grade Point Average
• Acquire a high school diploma
• Seek post-secondary education
• Improve school conduct
• Increase school attendance

Our team of skilled educators are at the Study Center every school day from 3:00pm to 7:00pm to assist students in completing their homework, in a safe environment conducive to learning. Students are assigned to one of three homework assistance schedules, with sessions beginning at 3:30pm, 4:30pm and 5:30 pm. beginning at one of those times, they spend about an hour in one of the Study Center’s classrooms, working on their homework.

Most students remain at the Study Center for 2-1/2 to 3-1/2 hours.

In addition to the homework assistance, we provide:
• A healthy snack
• Structured recreational activities
• A well-equipped and staffed library and computer lab for individual study

In order to participate in this program, you and your child must complete this form and provide the documents specified below.

Study Center students are expected to:
• Come to their assigned classroom on time, with all necessary text books and homework assignment sheets.
• Use their personal security badges to sign in and out of the Study Center.
• Abide by a code of conduct to that expected in the public school system.

How to Enroll
To enroll your child, please complete all spaces on the inside of this form.
The student then signs in one place and you (the parent or guardian) sign in two places.

You may submit the following via fax @ 561-620-6205
• A copy of the student’s most recent school report card
• A copy of the student’s birth certificate or school system student ID card

Student Information

Name:

Age:
Grade: Sex M F

School:

Ethnicity (check one):
White Black Hispanic Asian Amer. Ind. Other

Home Address / Apt #

City
State Zip

Phone

Date of Birth

Student ID #

eMail

Subject I like best are:

I would like help in:

I want my GPA to be:

As a member of the Wayne Barton Study Center, I promise to bring in a progress report from my teachers every 2 weeks. I also promise to bring in my report card every 9 weeks. I agree to follow all rules and regulations established by the administration and staff at the Study Center, as described in the Center’s Student and Family Handbook. I am aware that any disruptions or discipline problems may result in my being suspended or permanently dismissed from the Wayne Barton Study Center.

Student Signature:

Date:

Parent or Guardian Information

Parent/Guardian Name(s):

Home Address: Apt. #:

City:

State: Zip Code:

Evening Phone:

Daytime Phone:

Emergency Contact Name:

Emergency Contact Phone:

Alternate Emergency Phone:

As legal parent/guardian(s), I/We hereby give the above student permission to participate in the Wayne Barton Study Center’s education, recreation, and physical fitness programs. I/We agree to provide support and encouragement to our child as a participant in the Study Center. I/We give permission for the Wayne Barton Study Center program staff to request specific information from the student's school, including grades, attendance records, reports, and other data.

In consideration of our child's right to participate in the Study Center activities, I/We hereby waive, release and discharge any and all rights or claims which I/We may have against Barton's Boosters, its sponsors, their respective subsidiaries, affiliates, directors, officers, employees, members and staff (collectively "Barton's Boosters" sponsors) as a result of our child's participation in the Wayne Barton Study Center. Further, I/We agree to defend, indemnify and hold the sponsors harmless against any and all claims, actions or suits which may be brought as a result of damages or losses sustained as a result of participation in the Wayne Barton Study Center.

I/We understand and acknowledge that our child can and will be asked to withdraw from this program at the discretion of the program staff should the child become a disciplinary problem and/or disrupts the operation of the program. I/We also understand that students may occasionally be photographed or filmed for promotional purposes and I/We agree to have our child’s photo appear in news reports about the Center or in Study Center promotional materials or Web sites.

Parent/Guardian Signature:

Date:

Student Health Information

Does your child have allergies to any foods or medicines? Yes No

If yes, please list:

List:

Check below if your child has ever had the following conditions:

Low Blood or Anemia
Sickle Cell
Asthma or Wheezing
Seizures/Epilepsy
Broken Bones
Trouble with Hearing
Trouble with Seeing
Kidney/Bladder Infection
Heart Murmur/Heart Problems
Pregnancy
STD's
Convulsion/Fit/Spell
HIV
Hepatitis
Diabetes

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Other (describe)

List any medications your child is currently taking:

Additional health concerns or needs:

Primary Physician: Phone:

Health Insurance Carrier: Policy No.:

In the event of a serious accident or illness, I request the Wayne Barton Study Center to contact me. If I cannot be reached, the Study Center may make whatever arrangements are necessary to provide emergency care and treatment for my child. This may include conveyance to treatment at a hospital or other medical facility. I will assume responsibility for payment for services rendered. In case of an accident or illness where immediate treatment of my child is not necessary, but where he/she is unable to remain at the Center, I request that the Center attempt to contact me first at the numbers I have provided to arrange transportation for my child. In the event that I cannot be reached, please contact the emergency contact I have listed.

Parent/Guardian Signature:

Date: