After School Interest Form If you are interested in our after school program, please fill out the form below. Child's Name* First Last Suffix School*Select schoolAversboroBryan RoadCreech RoadEast GarnerRand RoadTimber DriveSmithVandora SpringsGrade*Select grade1st2nd3rd4th5thDoes your child qualify for free or reduced lunch?*YesNoChild's Gender*Select genderMaleFemaleParent/Guardian's Name* First Last Suffix Phone*Email* Enter Email Confirm Email Primary Language Spoken*EnglishSpanishWCPSS Release and Exchange of InformationThis consent is for the release and exchange of information for the purpose of sharing information on my child’s educational performance in the Wake County Public School System (WCPSS), to include his or her academic achievement and social-emotional development. The purpose of releasing and exchanging this information is to assist individuals to plan and provide a high quality after school educational program for my child. Individuals who WCPSS personnel can share this information in accordance with this release are limited to those involved in implementing Community of Hope Ministries. I hereby authorize WCPSS personnel to release and exchange specified information concerning my child’s educational performance with personnel associated with the above named agency. I understand that this information is to be used by personnel at the agency in planning and delivering educational, social-emotional, and recreational services to my child in the COHM after school program. By signing below I am allowing the following: a) Discussions with my child’s WCPSS school teacher(s) and other staff (e.g., administrators, specialists, counselors), as well as review of surveys about my child completed by these school staff; b) Data on my child’s report card grades, results of End-of-Grade and End-of-Course exams, and other group examinations; c) Other information that may be found in my child’s records at school, including his or her attendance at school and disciplinary incidents at school; The doctrine of informed consent has been explained to me. I understand the nature of the information to be released, the need for this information and use which will be made of this information, and that there are statutes and regulations requiring recipients of this information to maintain the confidentiality of the information and use it only for its intended purposes in the COHM program. I hereby acknowledge that this consent is truly voluntary, and understand the consent will expire automatically on June 30, 2020. I further acknowledge that I may revoke this consent in writing at any time except to the extent that action based on this consent has been taken.Signature*I agree to allow WCPSS to release information to COHM for the purposes of checking eligibility.After School Interest Agreement*By checking the box below, I understand that submitting this form does not qualify or secure my child a spot in the after school program at Community of Hope Ministries. I agree UntitledFirst ChoiceSecond ChoiceThird ChoiceCommentsThis field is for validation purposes and should be left unchanged.