Tarrant County College South Campus Generation Hope

Aplicación de Estudiante

Requisitos PARA ESTUDIANTES NUEVOS: • Permiso de los padres• Aplicación completa• 1 Ensayo• 1 Recomendación del maestro (English, math or science teacher)• Copia de la libreta de calificaciones del año pasado• Asistir a la sesión de orientación del programa

Requisitos PARA ESTUDIANTES VUELVEN:

• Permiso de los padres• Aplicación completa

Generation Hope es "por orden de llegada", asegúrese de que su solicitud esté completa y enviada!

Direcciones 1. Completa la solicitud en tinta negra o azul2. Ensayo: imprima con tinta o escribe un ensayo de 100-200 palabras respondiendo la siguiente

pregunta: What do you hope to gain from Generation Hope?3. Envíe su solicitud completada:

a. Scan and email to generation.hope@tccd.edub. Fax to 817-515-0551c. Mail to or deliver to:

Tarrant County College South CampusAttn: Generation Hope/Erika Zimmermann Community Education & Engagement5301 Campus Drive Fort Worth, Texas 76119

You can expect to receive a response within a week of submitting your application. If you have any questions, please contact Erika Zimmermann at 817-515-4392 or generation.hope@tccd.edu TCC and the Generation Hope Program are an Equal Opportunity Institution/Equal Access to persons with

disabilities.

FOR OFFICE USE ONLY

RECEIVED INIT. ________

COMPLETE / INCOMPLETE

INCOMPLETE CODES:

( ) A ( ) E ( )G ( ) N

DATE COMPLETED:

__/__/__ INIT. ________ MATH

__ __ __ ___ / __ __

SCIENCE

__ __ __ __ / __ ___

ENGLISH

__ __ __ / ___ ___ __

NOM. _______ ESSAY: YES / NO CONDUCT ________ ACCEPT: ______ BY: _________

Generation Hope aplicación de estudiante

INFORMACIÓN PERSONAL Apellido

Género: ___Niño ___Niña

Nombre

Fecha de nacimiento _________ Número de Identificación

Etnia: Americano Indio Anglo Afroamericano Hispano Asiático Otro

Dirección

Ciudad Estado Código Postal

Número de teléfono E-mail

_____7 _____8

Distrito

Relación

INFORMACIÓN DE LA ESCUELA ACTUAL Nivel de Grado 2019-2020 _____6

Nombre de la escuela

INFORMACIÓN DEL PADRE/GUARDIÁNNombre

Dirección (si es diferente del estudiante):

Número de teléfono Número de trabajo Ext.

Celular E- mail Address

¿El estudiante vive con usted? ____Sí ____No ____N/A

INFORMACIÓN DE CONTACTO EN CASO DE EMERGENCIARelación

Número de trabajo Ext.

Nombre

Dirección (si es diferente del estudiante):

Número de teléfono

Cell Phone ( )

PERMISO DEL PADRE/GUARDIÁNPor favor inicie para mostrar su acuerdo con cada una de las siguientes declaraciones:

Soy el padre/tutor legal del estudiante.

Entiendo que Generation Hope es un programa riguroso y exige la habilidad y la motivación del estudiante para completar el trabajo de clase y tareas complejas con esfuerzo y atención.

Doy permiso para que mi hijo(a) asista el programa de Generation Hope.

Entiendo que mi hijo(a) debe asistir al programa Generation Hope de la semana de octubre a mayo. Entiendo que se permite solo tres ausencias justificadas. También entiendo que mi hijo(a) tendrá trabajo de clase.

Entiendo que mi hijo(a) debe seguir todas las reglas de Generation Hope y del distrito escolar.

Entiendo que Generation Hope tiene una política firme al respecto de incumplimiento de las reglas y políticas de Generation Hope y / o del distrito escolar. En el caso de una violación de regla / política, el director puede despedir al niño del programa. Algunos ejemplos de violaciones de reglas incluyen, pero no limitado a: copiar exámenes, plagio, irse del campus sin permiso, dañar propiedad, violencia física, activar alarmas de incendio o repetición pequeñas infracciones.

Entiendo que soy responsable del transporte de mi hijo (a), si no toman el autobús.

Fecha

Fecha Firma de padre/tutor legalFirma de estudiante

Generation Hope TEACHER NOMINATION FORM

DIRECTIONS: Please return this form to the student upon completion. It must be attached to the rest of his/her application and submitted to Generation Hope.

PART 1 - TO BE COMPLETED BY APPLICANT

Full Legal Name: LAST__________________________ FIRST______________________ MI______

Current Grade Level: � 06 � 07 � 08

2019-2020 School Attending__________________________________________ School District ___________

PART 2 - TO BE COMPLETED BY THE TEACHERGeneration Hope is a rigorous and demanding program designed for motivated students with the ability to successfully learn and complete complex class work and homework above and beyond standard school instruction. He/she is being considered for admission to Generation Hope. Please give us your honest assessment of this student’s desire and ability to learn.

A. PLACE AN "X" IN THE APPROPRIATE COLUMN FOR EACH CHARACTERISTIC LISTED.CHARACTERISTIC EXCELLENT GOOD FAIR POOR

ACADEMIC PERFORMANCE CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME ANALYTICAL THINKING SKILLS MATURITY PUNCTUALITY EAGER TO LEARN NEW THINGS STUDENT IS SUFFICIENTLY MOTIVATED TO COMPLETE AN AFTERSCHOOL PROGRAM

B. Please provide comments on motivation, behavior, personality, strengths or weaknesses you feel arepertinent to the student’s performance in Generation Hope. Additional comments may be written onthe back.

C. Current course you are teaching applicant__________________________________________________

TEACHER'S PRINTED NAME/TITLE SCHOOL TELEPHONE NUMBER

TEACHER'S SIGNATURE DATE

______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

__________________________________ ___________ _________ _____________ __________________________________ ____________ _________ _____________ __________________________________ ____________ _________ _____________

________________________________________ ________________________

Voluntary Minor Student Health Information and Consent to Emergency Treatment

Name: ___________________________________ DOB: ____________ Date: ________Campus: _________________________________ Student ID: ________________________

Parent/Guardian: _____________________________ Home #: Cell #: _____________________________________ Work #: Parent/Guardian: _____________________________ Home #: Cell #: _____________________________________ Work #:

In case of an emergency and parents cannot be reached, who should be contacted? 1. Name : ______________________ Relationship to Student:

Home #: Cell #: _______________ Work #:

2. Name : ______________________ Relationship to Student:Home #: Cell #: _______________ Work #:

Physician: __________________________________ Phone #: Preferred Hospital: ___________________________ Phone #:

Allergic to (meds, food, insects, etc.): Type of reaction (rash, difficulty breathing, etc.):

Current medical diagnoses or disabilities:

Past injuries/illnesses/hospitalizations/surgeries:

List any medications currently taking below.

Medications Strength Dose Time Given:

Consent to Emergency Treatment Tarrant County College District is an educational institution in which _______________________, a student, at the College has received written authorization to consent to emergency medical treatment from a person having the right to consent as follows: I, _______________________________________, the __________________________ [relationship to student] grant Tarrant County College permission to authorize emergency medical treatment to the above named student in the event that the College is unable to contact me. This authorization shall remain in effect until revoked by me in writing and delivered to TCCD. The undersigned is responsible for all medical costs associated with this authorization. Furthermore, no liability is attached to either TCCD or any of its members and staff for such action.

Signature of Parent or Legal Guardian Date Tex. Family Code § 3 2.001

Informed Consent and Assumption of Risk Form

This form needs to be signed by all participants, students, guests, and other non-employees participating in act i vi t i es o r even t s . Students/ Participants under the age of 18 are required to obtain a signature from a parent or legal guardian.

(INSERT NAME OF ACTIVITY OR EVENT)

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

I, ("Participant"), hereby acknowledge that I have voluntarily elected to participate in the following activity or event __________

(the "Activity"), to be held in and around the following location ,on _________.

In consideration for being permitted by Tarrant County College District (the "DISTRICT") to participate in the Activity, I hereby acknowledge and agree to the following:

RULES AND REQUIREMENTS: I agree to conduct myself in accordance with DISTRICT policies and procedures. I further agree to abide by all the rules and requirements of the Activity. I acknowledge that DISTRICT has the right to terminate my participation in the Activity if it is determined that my conduct is detrimental to the best interests of the group, my conduct violates any rule of the Activity, or for any other reason in the DISTRICT's discretion. Failing to follow rules of the Activity, staff directors, or the Student Handbook may result in disciplinary action. If I am told to leave the Activity as a result of my failure to follow the rules and requirements of the Activity or the directions of the staff directors, transportation from the Activity will be at my expense.

INFORMED CONSENT: I have been informed of and I understand the various aspects of the Activity, including the dangers, hazards, and risks inherent in the Activity, including but not limited to transportation to and from the Activity and/or the DISTRICT via private vehicle and/or common carrier, participation in the Activity, overnight accommodations, weather conditions, conditions of equipment, facility conditions, negligent first aid operations or procedures, and in any independent research or activities I undertake as an adjunct to the Activity. I understand that as a participant in the Activity I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only DISTRICT's actions or inactions, but also the actions, inactions, negligence or fault of others and despite safe precautions, DISTRICT cannot guarantee safety thereof and all risks cannot be prevented.

RELEASE AND WAIVER OF LIABILITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE,DISCHARGE, AND COVENANT NOT TO SUE DISTRICT, its governing board, directors, officers, employees, faculty, agents, volunteers and any participants or students (hereinafter referred to as "Releasees") for any and all liability, including any and all claims, demands, causes of action

(known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Activity, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON,UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY,OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any injury or damage that Isustain as a result of my own negligent acts.

ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation in the Activity, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage, or even death. I understand that there are potential risks as a consequence of, but not limited to: participation in this Activity, travel to and from DISTRICT via private vehicle or common carrier, weather conditions, overnight accommodations, facility conditions, equipment conditions, first aid operations or procedures of Releasees, and other risks that are unknown at this time. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OR OMISSIONS OF THE RELEASEES and assume full responsibility for my participation in the Activity.

INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all cost, expense or liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage, or death that I may suffer as a result of my participation in the Activity.

FERPA: I consent to the release of my records that are protected by the requirements of the federal Family Educational Rights and Privacy Act (20 U.S.C. Sec. 1232g, 34 CFR Par.99), but only in conjunction with the Activity, and I release the Releasees from any and all damage and liability, including any and all claims, demands, causes of action (known or unknown), suits or judgments of any and every kind (including attorney’s fees) arising from any damage, cost or expense I may suffer or incur as a result of the release of such records.

PERSONAL MEDICAL INSURANCE: I further acknowledge that I am responsible for the cost of any and all medical and health services I may require as a result of participating in the Activity.

CERTIFICATION OF FITNESS TO PARTICIPATE: I attest that I am physically and mentally fit to participate in the Activity and that I do not have any medical record of history that could be aggravated by my participation in this particular Activity. If I require any reasonable accommodation(s) in order to participate in the Activity, I have notified the sponsor in writing of the nature of the accommodation(s) needed prior to the Activity.

MEDICAL CONSENT: I understand and agree DISTRICT is not responsible for my health and safety. Recognizing this, however, I wish to, and hereby do, grant DISTRICT full authority to take, or not to take, in its sole discretion, whatever actions it may consider warranted under the circumstances for my health and safety during my participation in the foregoing event, and I hereby release it from any liability for any such decisions or actions as may be taken in connection therewith.

The authority granted in the preceding sentence shall include the right (in the sole discretion of DISTRICT) to place me, at my own expense, and without any further consent, in a hospital, for medical services and treatment, or if no hospital is readily accessible, to place me in the hands of a local medical doctor for treatment. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.

CHOICE OF LAW: I hereby agree that this Agreement shall be construed in accordance with the laws of the State of Texas.

SEVERABILITY: If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND IHAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT IAM AT LEAST EIGHTEEN YEARS OF AGE OR, IF NOT, THAT IHAVE SECURED BELOW THE SIGNATURE OF MY PARENT OR GUARDIAN AS WELL AS MY OWN.

Name of Participant TCCD Student ID Number

Signature of Participant Date

Signature of Parent/Guardian for Participants under eighteen (18) years of age:

I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I join with Participant in granting a release to Releasees as set forth in detail above.

Signature of Parent or Guardian Date

EMERGENCY CONTACT:

Name:

Relationship:

Phone Number: