HIGHER ACHIEVEMENT AFTER SCHOOL ACADEMY 2009-2010

CONFIRM YOUR SPOT/UPDATE INFORMATION FORM

If you do not complete this form and return it with the required attachments, you risk losing your spot!
 Ward 1: Adams School,  Ward 4: Brightwood ES, Ward 6: Ludlow Taylor ES,
CENTER PREFERENCE 2020 19th St. NW, WDC, 20009 1300 Nicholson St. NW, WDC 659 G St. NE, WDC, 20002
20011
 Ward 7: Kelly Miller MS,
301 49th St. NE, WDC, 20019  Alexandria: Hammond MS,
SCHOLAR INFORMATION 4646 Seminary Rd, Alexandria

First Name Middle Name Last Name Age Date of Birth (Month/Day/Year)

School in the Fall Grade in the Fall School ID Number (from report card, if applicable)

Home Address City State Ward (if applicable)

Zip Code

Home Telephone Number Scholar’s E-Mail Address

PARENT/GUARDIAN INFORMATION

First Name Middle Name Last Name Relationship to Scholar

Home Address City State Zip Code Home Telephone Number

Employer Work Telephone Number Mobile Telephone Number Parent/Guardian E-Mail

Address

NECESSARY ATTACHMENT

CHOOSE INSURANCE CARD OPTION  Copy Enclosed  Will submit copy by September, 7th 2009  Have no
proof of insurance
(This is needed in the event of an emergency to allow your child admission to a medical facility.)

MEDICAL INFORMATION

Emergency Contact #1 Relationship to Scholar Home Telephone Number Work Telephone Number Mobile
Telephone Number

Emergency Contact #2 Relationship to Scholar Home Telephone Number Work Telephone Number Mobile
Telephone Number

Health Insurance Carrier Policy Number

Please list any allergies your child has Please list medications your child takes on a regular basis

Please list any special physical conditions your child has

I (Parent/Guardian’s Name), hereby give my permission for Higher Achievement staff or volunteers
to seek medical attention or administer first aid in the event of an emergency, or to administer any medications that my child
is taking. I also agree to assume financial responsibility for such treatment.

 Please check here if any of the above information has changed since your last application/Confirm Your Spot Form.

By signing below, I confirm the above information is accurate.

Whether or not my child participates in Higher Achievement, I grant Higher Achievement:
 Permission to obtain copies of my child’s report cards, Individualized Education Plans (IEPS), and standardized test scores from
school at any time(s) until he/she completes grade 12.
 Permission to open an email account in child’s name.
 Permission to use, publicly, photos of my child’s participation and work they have produced while attending Higher Achievement.
 Permission for my child to ride in a vehicle driven by Higher Achievement staff or volunteers for Higher Achievement related
activities.
 Permission to track aggregate Scholar data and share the results.
I also agree to waive any claims or lawsuits against Higher Achievement that may arise in connection with my child’s participation in
the program. To the extent allowed by law, this waiver includes any claims of negligence or other allegations of wrongdoing by Higher
Achievement.

Parent Signature Date Scholar Signature

Date