Application for Admission
to MHC After 3 – Middle School

c/o Patrick Henry Community College
645 Patriot Ave. Martinsville, VA 24112

2017-2018 School Year

*Home Phone #
Name Student Goes By
Student Cell Phone #
Student Email Address
*Parent Email
*Mailing Address
*City *State *zip
*Student lives with
*Does your child have an IEP or a 504 Plan?
*Grade as of 17-18 School Year
*Free or Reduced Lunch: Yes    No    Did not apply
T-Shirt: Adult Sizes S   M    L    XL    XXL   
*Please indicate the site(s) your child would like to attend during the school year:
Bassett Community Center
Fieldale Middle School
Stone Memorial
Laurel Park Middle School

    *American Indian   Hispanic   Asian   African American    White   Multi-Racial   Other
Are you Enrolled in Other After School Programs?   []No []Yes
The Program Name is
Describe yourself in 10 words or less:
What do you like about school:
What clubs/sports/activities do you participate in currently:
 What do you like?
College Exploration
Leadership Skills
Outdoor activities/Hiking
Communication Skills
Summer Camps
Trying new things
Career Exploration
Going newplaces & making friends
Social/Cultural Activities
Poetry/Creative Writing
Water Sports (Canoe/Kayak/Fishing)
Board Games
Culinary Arts (Cooking)
 PARENT /GUARDIAN INFORMATION *****Must be completed and signed by a parent*****

*Parent 1 OR Guardian 1 Name
Home Phone
Work Phone
Cell Phone

Parent 2 OR Guardian 2 Name
Home Phone
Work Phone
Cell Phone

*Emergency Contact Name 1 (other than the parent or guardian)
Home Phone
Work Phone
Cell Phone

*Emergency Contact Name 2 (other than the parent or guardian)
Home Phone
Work Phone
Cell Phone
*Who is authorized to pick up your child?
Relationship to Child

Is there anyone who is unauthorized to pick up your child? (Official documentation is needed)
Relationship to Child

Please indicate if you would be interested in serving on our Parent’s Advisory Committee: Yes     No

 STUDENT MEDICAL INFORMATION *****Must be completed and signed by a parent*****
*Family Doctor or Clinic
*Insurance Provider
*Policy Number
*Please indicate allergies and medical conditions of your child
*Does your child experience motion sickness? Yes   No
*Is your child a proficient swimmer? Yes   No
*Is your child a proficient bike rider? Yes   No
*Are there any foods your child should not eat?
*Does your child have any physical limitations?
*Does your child require an epi-pen? Yes   No
*List any medications your child is currently taking?
*Does your child have any special needs of which staff needs to be aware

Yes, MHC After 3 staff may perform basic first aid on my child to such as applying a band aid and providing a cold pack.
Yes, please call me for authorization if my child is requesting over-the-counter medications such as pain relievers or motion sickness tablets.
Yes, please provide my child with feminine hygiene products as needed.

*MHC After 3 does not have all medications or feminine hygiene products. Parents and students should not rely on the program to provide these items.

Parent Agreement:

I understand that the information I have provided here is for the use of MHC After 3 and partner agencies only and will remain confidential. I relieve the program of any responsibility for any accidents, illnesses, or injuries which may result from participation and allow them to take pictures for program documentation and promotion. I give my permission for MHC After 3 to review my child’s school records for the purposes of recording grades, reviewing test performance and reviewing school attendance rates.
Be it known that I, as parent/guardian of the named student, hereby grant unto any medical doctor or hospital my consent and authorization to provide such aid, treatment, or care to said student as, in judgment of the doctor or hospital, may be required on an emergency basis in the event said student should be injured or stricken ill while participating in an IMIN/MHC After 3 sponsored event or field trip.

Yes, my child has permission to participate in fieldtrips, activities and events sponsored by MHC After 3

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Student Agreement:

I would like to be a participant in the MHC After 3 Program. If I am accepted into the program, I agree to abide by ALL of the rules and regulations of the program, and participate in all activities. I will be respectful to staff and peers participating in the program on and offsite. I understand that violation of any of these may result in my suspension from the program.

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