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.
Click
here if you wish to submit the enrollment kit via eMail
or
You
may print
and submit this form to the Study Center, along with:
• 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
submit
to:
Wayne
Barton Study Center
269
N.E. 14th Street • Boca Raton, Florida 33432
Student
Information
Student Name: Age: Sex
M
F
Ethnicity (check one):
White
Black
Hispanic
Asian
Amer. Ind.
Other
School: ______________________________________ Grade:
____________
Home Address: Apt. #: ________________________________________________________________________
City/State: Zip Code: __________________________________________________________________________
Phone Number: ______________ Date of Birth: _____________
Student ID No.: _______________
Subjects 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:
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: __________________