Ten West Academy Application (Office Use Only)

Program (check one) Student Information Name (Last, Middle, First): ________________________________ Date__________ Age: __________ Birthdate (MM/DD/YY): ___________________ Gender_________ Address: _____________________________________________________________ Address #2 (if applicable): ________________________________________________ Guardian Information #1 Name: ______________________________________ Birthdate (MM/DD/YY): ___________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: __________________________ Work Phone: _______________________ Home Phone: _______________________ #2 Name: ______________________________________ Birthdate (MM/DD/YY): ___________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: ___________________________ Work Phone: _______________________ Home Phone: _______________________

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Program 1-2 Days Weekly

1-2 Days Monthly

3-5 Days Weekly

3-5 Days Monthly

2:30pm 4pm

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EMERGENCY CONTACT INFORMATION In case of emergency, who should Ten West Contact to be with your child? (Please list at least one person other than a guardian) #1 Name: ______________________________________ Relationship: ______________ Birthdate (MM/DD/YY): ___________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: ___________________________ Work Phone: _______________________ Home Phone: _______________________ #2 Name: ______________________________________ Relationship: _____________ Birthdate (MM/DD/YY): ___________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: ___________________________ Work Phone: _______________________ Home Phone: _______________________ MEDICAL INFORMATION Doctor’s Name: ____________________________________________ Address: _________________________________________________ Phone: ___________________________________________________ Blood Type: ____________ Allergies: __________________________________________________ Medical Conditions: __________________________________________

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Ten West Center for the Arts WAIVER AND RELEASE FROM LIABILITY

Ten West Academy

August 2012-June 2013

  By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with Ten West Center for the Arts activities and events organized by Ten West Academy. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights in these specific areas:

• PARKING: Participant expressly waives all claims of Liability against Ten West Center for the

Arts arising out of the Participant using the parking facilities.

• TRANSITIONAL SPACES: Participant expressly waives all claims of Liability against Ten West Center for the Arts arising out of the Participant using stairwells, hallways, and restrooms while transitioning to the Community Room.

• CLASS ACTIVITIES: Participant expressly waives all claims of Liability against Ten West

Center for the Arts arising out of the Participant participating in class activities and/or using classroom space.

I have signed this Agreement freely, voluntarily, under no duress. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 years of age or older and mentally competent to enter into this waiver. Printed Name of Participant ___________________________________ Date___________ Signature of Participant (if under the age of 18, signature of parent or guardian): ___________________________________ Date_____________

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ACADEMY BEHAVIOR POLICY

Ten West Academy understands that everyone makes mistakes, and those mistakes are great learning opportunities, but we also stress that enrollment at Ten

West Academy is a privilege that can be revoked. Please review our code of conduct and our accountability guidelines that spell out the disciplinary actions that

will come out of different infractions.

TEN WEST CODE OF CONDUCT • Respect

o There is a zero tolerance policy on bullying and put-downs. Students are expected to give respect to get respect.

• Integrity o “To do what you know is right.”

• Cooperation o Students are expected to work together and do their best every day.

• Honesty o Students should always tell the truth. To teachers, staff, other students,

and anyone else that may be in the building. • The Law

o Anything that would get a student in trouble with the police is cause for immediate expulsion from the Academy. Stealing, fighting, vandalism, drug abuse etc.

• Dress o Students are not permitted to wear clothing promoting drugs, sex, or

alcohol. Students must wear a form of footwear (shoes, flip flops sandals).

__________________________________________________________________ DISCIPLINARY ACTION

1st Offense: Verbal Warning 2nd Offense: Written Referral 3rd Offense: Parents Contacted 4th Offense: Possible Suspension from Academy 5th Offense: Possible Expulsion from Academy *Administration reserves the right to apply best judgment in individual situations and use this course of action as a guideline for discipline.

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BEHAVIOR PLEDGE

I _________________ promise to respect others, do what I know is right, and be cooperative and honest. I will be helpful and kind. I will do my best every day and keep a positive attitude. I know that if I do not follow the rules, I will have to face the consequences. __________________________________ Students Signature

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STUDENT PICK UP Safety is our first priority at Ten West. To maintain a secure building, guardians or appointed adults must sign students in and out of the building. The only exceptions are students arriving on school buses or on Ten West shuttles. A guardian must still sign them out. Please list guardians and/or appointed adults to pick up your student below. If an adult other than one of those listed here must pick up a student, a

parent or guardian must notify the office in person as to who that adult is. Designated Pick Up Information Driver #1 Name: ______________________________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: ___________________________ Work Phone: _______________________ Home Phone: _______________________ Driver #2 Name: ______________________________________ Address: _____________________________________________________________ Cell Phone: ________________________ E-mail: ___________________________ Work Phone: _______________________ Home Phone: _______________________