Form Center

Enrollment Agreement: I have received, read and fully understand all the policies and procedures contained in the 21^st Century Schools Handbook. I hereby agree to abide by all the policies and procedures therein. I further give my consent to the school district and 21^st Century Schools to share participant records with each other for the purposes of providing educational support and assistance. In addition, I understand that participant records will be used to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program. In conclusion, I wish to enroll my child in the 21^st Century Schools program offered by the Tazewell County Health Department.

Internet Usage: I am familiar with and understand my child’s School District Internet Policy. I understand that the same terms and conditions listed in the District’s Internet Policy apply during Internet usage while in the 21^st Century Schools program. Internet access is designed for educational purposes and the District and TCHD have taken precautions to eliminate controversial material. However, I also realize it is impossible for the District and TCHD to restrict access to all controversial and inappropriate materials. I will hold harmless the District, TCHD, their employees, agents, or board members for any harm caused by material or software obtained via the network. I accept full responsibility for supervision if and when my child’s use is not in a school setting. I have discussed the terms of authorization with my child. I hereby request that my child be allowed access to the Internet on a district computer during time spent at the TCHD program

Photo Release: I give my permission for 21st Century Schools to use pictures or videos, either taken by staff, newspaper or television photographers, in the promotion of the afterschool program. 

Movie Agreement: I understand that movies will be watched during the 21st Century Schools program. There will be times that a PG movie may be viewed. If there are particular movies that you do not want your child to view, please notify our staff in writing. I will hold harmless the District, TCHD, their employees, agents, or board members for any harm caused by materials obtained during the viewing of the movie. I accept fully the responsibility for allowing my child to view these movies. I hereby request that my child be allowed access to view these movies during the time spent in the before and afterschool programs.

In the event that my child requires medical and/or surgical care while I’m unable to be reached, I hereby give my consent for medical and/or surgical treatment for the child listed above. I agree to pay all costs and fees contingent for any emergency medical care and/or treatment for my child as secured or authorized under this consent. 21^st Century Schools will make every effort to notify parents and caregivers immediately in case of emergency.

Student Medical Information

Student and staff safety is very important. In addition to the rules enforced during the school day, the basic rules of 21^st Century Schools are:

1. Be Kind – to yourself, each other and the environment (books, desks, etc.)
2. Be Respectful – follow directions and rules; Verbal harm (hurtful words) will not be allowed
3. Be Productive – do your assignments; find productive activities; cooperate

Participants will follow the Behavior Card System. The rules and punishment will be the same for all students unless there is a written discipline plan on file. The Behavior Card System will be implemented as follows:

At the beginning of each session each student will begin on Green.

Green Card                    Good Behavior

Yellow Card                 1^st Behavior Violation (Verbal Warning) 

Red Card                       2^nd Behavior Violation (Note Sent Home)

Blue Card                     3^rd Behavior Violation = Strike (Incident Report)

3 Strikes/Incident Reports will result in removal from the 21^st Century Schools program.

In the case of a student harming or threatening harm to property, themselves, other students or staff, continually not following staff instructions, disrupting activities, using illegal substances, or any other endangering behavior, the child may be immediately removed from the program without going through the protocol listed above. Internet offenses follow are cause for immediate removal of computer privileges. Students may be temporarily suspended from 21^st Century Schools programming pending investigation.

When removal is warranted according to the protocol listed above, the 21^st Century Schools Director and the School Principal will be notified prior to its implementation. The Site Coordinator, School Principal and the Director of 21st Century Schools will then determine the length of program removal. The length of program removal will be no shorter than 2 weeks. In some cases, the severity of the student’s behavior would make return unacceptable. Multiple discharges from the program are also cause for permanent removal.