After School Enrichment Program, Fall 2017

After School Enrichment Program, Fall 2017

Registration Form

Classes Run for six weeks on Tuesdays from October 10 November 21*

*No class November 7, student holiday. Class dates are: Oct 10, Oct 17, Oct 24, Oct 31, Nov 14, Nov 21.

REGISTRATION CHECKLIST: (No on-line registration) REGISTRATION FORM DUE MONDAY, OCTOBER 2

Registration or Scholarship Application completed and signed PLEASE PRINT LEGIBLY

Emergency & Permission form completed and signed

$5 check payable to EMES PTA for ASEP registration

Check made out to the instructor for $45 plus any additional supply fee required, as listed in the class description

Place all items in an envelope and return to school to the Attention: PTA ASEP *We will ensure the instructor receives their payment prior to the first day of class, once we confirm your registration is complete.

General Program Information

Classes run on Tuesdays, Oct 10 Nov 21*, from 2:45-3:45 p.m. (*No class Nov 7, student holiday)

Registration is first come, first served (All forms must be completed to register your child)

PAYMENT: You must write two checks: one to instructor and one to EMES PTA, as follows:

Instructor payment: Check payable to instructor is equal to $45 for registration (except for Pinterest club, which is $60, as it includes a $15 supply fee)

Registration fee: Check of $5.00 per student, payable to EMES PTA

Scholarships are available; please complete the scholarship registration request form

Emergency contacts must include someone who can pick up your child if we cannot reach you

ASEP pickup time is 3:45 sharp. This is a program requirement. On any class day, if you have not picked up your child by 3:50, you or your emergency contact will be called to pick up your child.

WEATHER: ASEP classes are cancelled when there is early dismissal or evening activities are cancelled; the ASEP program follows the LCPS schedule

When an emergency cancellation occurs, you will be contacted by the instructor or ASEP to change after school directions for your child

NO REFUND AFTER SESSION BEGINS (Classes may be cancelled prior to first session if enrollment is low.)

*DEADLINES:Registration begins Friday, Sept 22 & ends Monday, Oct 2, 2017

Student Name____________________________ Grade _____Teacher_______________________

**To register, please Circle the class your child would like to attend. Please use a separate form for each child. **

CLUB NAME

Description/Location (Class minimums and maximums)

Grades

SPORTS MIX CLUB

with Mr.Mark Bauer

This high-energy club has students playing fun games while learning new skills and making new friends. A different sport will be covered each week with games to complement what the students have learned. MEETS IN GYM

Club Minimum: 12, Maximum: 30

3rd

4th

5th

INTRO INTO SPORTS ACTIVITIES

with Mr.Jason Lutman

Precursor to the Sports Mix club, for grades 1-2.Wewill focus on the development of skills for multiple sports over a six-week period, including the skills of Over and Underhand throws, catching, kicking, and striking. The students will then use these skills to participate into lead up games for sports such as football, baseball/softball, kickball, soccer, and volleyball. MEETS IN GYM Club Minimum: 15, Maximum: 30

1st

2nd

PINTEREST PARTY withMrs. Ginger Walley

Are you crafty and creative? Come join us as we have a Pinterest Party every week! During each class session, we will create a cool craft project found on Pinterest. Participants will have input on which particular projects they would like to create. Meets in CLASSROOM #12 Club Maximum: 15

*Additional SUPPLY FEE of $15 required.*

2nd

3rd

4th

5th

WORD NERDS

with Kathy Goodhart and Jennifer Ashford

Bashful bookworms! Raucous readers! Voracious verbalists! COME ONE, COME ALL! In this enrichment class, we will combine our love of reading with preparation for the National WordMasters Analogy Challenge. Each class will be divided between a book club discussion and an exploration of new vocabulary words. During the last class, the students will take part in a National WordMasters Meet, consisting of 20 analogies. Students will have the option to participate in two additional WordMasters tests in February and April. Our 2-3 book club books will be determined based on enrollment and availability, but will be age-appropriate and discussion-worthy. Meets in CLASSROOM #7Club Maximum: 12

*Additional supply fee: $10 to cover cost of WordMasters program and books.

4th

5th

USTMA TAEKWONDO Rise Up Kids Program

with Master John Choi

**Please make your

check out to USTMA

This unique and fun 6-session character development program will benefit your child at home, at school, and in team activities and sports. The program blends martial arts with the life skill lessons such as concentration, listening skills, cooperation, respect, and courtesy. The program is taught by a certified Black Belt instructor and master from the United States Taekwondo Martial Arts Academy (USTMA). Class 1 Focus, Class 2 Cooperation, Class 3 Self-Control, Class 4 Respect, Class 5 Discipline, Class 6 Confidence! A White Belt Graduation ceremony will be scheduled from Nov 21-24 at USTMA headquarters located at 9 Cardinal Park Drive in Leesburg, so you may see your child demonstrate the power of focus through Taekwondo! Meets on the GYM STAGE Club Minimum: 10, Maximum: 15

1st

2nd

3rd

4th

5th

Scholarship Application

Deadline is 3:00 pm, Monday, October 2

Some of the classes may offer a scholarship opportunity to attend a Fall 2017 After School Enrichment Program (ASEP) club. All scholarship requests will be collected and placed into a box to be randomly selected by Mr. Pellegrino. Due to the limited amount of scholarships available, please only apply if participating truly poses a financial burden to your family. Only applications submitted by the deadline will be considered. Please complete one scholarship application per student, and return it to your childs teacher. Please note that you can apply for a scholarship in one of the below clubs assuming your student meets the grade level requirements.

Fall ASEP clubs run on Tuesdays for six weeks starting on Tuesday, October 10th. Students will need to be picked up when the ASEP program ends promptly at 3:45 p.m., or join CASA (if they are enrolled in CASA).

The following ASEP clubs are being offered this session. The PTA grants 1 scholarship per student based on need. Please indicate which club you are interesting in having your student apply for a scholarship by placing an X in the applying for scholarship column. You will be notified of receipt of your application and if you have been granted a scholarship for your student to attend the requested club.

Club Name

Eligible Grades

Applying for Scholarship?

Intro to Sports Club

1st, 2nd

Sports Mix Club

3rd, 4th, 5th

Pinterest Craft Club

2nd, 3rd, 4th, 5th

Word Nerd Book Blub

4th, 5th

USTMA Taekwondo

1st, 2nd, 3rd, 4th, 5th

CHILDS NAME:_______________________________ GRADE:_______ Childs Homeroom Teacher:__________________

Parent/Guardian Name(s): ___________________________________________________________________________

Phone #s (Cellular):________________________________________________________________________________

Phone #s (Home):________________________________________________________________________________

E-mails:____________________________________________________________________________________________

Parent Signature: __________________________________________________ Date: _______________________

Emergency Information Form

Participants Name: ______________________________________________________________________

LastFirst

Parent/Guardian Name: ___________________________________________________________________________

Email: _________________________________________________________________________________________

Participants address: ______________________________________________________________________________

Home Phone___________________________ Cell Phone(s)_______________________________________________

*Below list person(s) other than you who may pick your child up.

In case of emergency, please call: ______________________________________________________________________

Phone number(s) ________________________________ Relationship to participant: ____________________________

Participant Medical/Insurance Data:

Family Doctor: ______________________________________ Phone: ____________________________________

Any Allergies: _________________________________________________________________________________

Name of Insurance Company providing medical coverage: _____________________ Policy# __________________ __________________________________________________________________________________________________

Permission Form/Agreement to Participate:

I am the parent/guardian of (students printed name) _________________________________ and give permission for my child to participate in the ASEP program. I understand that there may be risks of injury involved in the activity and the student agr