 | ||||||
| ||||||
| ||||||
*Student's Full Name:
PERSONAL INFORMATION
*Zip Code:
*State:
*Age:
*Grade:
*Birthday
* Home Phone Number:
EMERGENCY INFORMATION
*Student lives with:
IN CASE OF INJURY, ILLNESS, OR DISASTER, and parents are unavailable, who may take student home or to your physician:
*Gender:
*1st Contact Full Name:
*2nd Contact:
*1st Contact Relationship:
*2nd Contact Relationship:
*Cell Phone1:
*Cell Phone2:
*Physician
*Health Plan:
*Physician's Address/City:
*Physician's Phone:
SCHOOL INFORMATION
*Last school attended: If Home Schooled, please state.
*School Address:
*Number of Siblings:
*School City:
*School Zip:
*School District Enrolled (if home-schooled indicate)
*District Address:
*District City:
*District Zip:
*Siblings Name(s) & Ages:
IN CASE OF AN EMERGENCY AND I CANNOT BE REACHED, I GIVE MY CONSENT TO HAVE SUCH ATTENTION GIVEN TO MY CHILD AS MAY BE THOUGHT NECESSARY BY A NURSE, PHYSICIAN, PARAMEDIC, OR HOSPITAL IN CHARGE.
*Parent/Guardian (Authorizing Enrollment):
*Please provide email address that you open daily. Email:
Registration Fee
There is a one-time registration fee of $50/per student which covers the cost of the student's program Uniform and program binder. Students will receive lots of information, training and development during the course of the program. The program services are at "no cost," based upon fundraising participation. Each student will need to raise $250 through fundraising or by donation/sponsorship. Scholarships may be available, if your family qualifies. Please check this box if you believe you need to apply for one.
*T-shirt: Please select your child's T-Shirt size below:
* Pants: Please select your child's/youth's B.D.U Pant size by viewing Sizing Chart and noting below size.
Please measure your child/youth for the following (in inches):
Waist (belly button level):
Inseam (Crotch down pass the ankle):
Hips (around widest part):
* Hat: Please select your child's/youth's hat size by viewing Sizing Chart and noting below size here
Total Online Registration Fee total per child/youth will be $51.80 (includes $1.80 wire transfer fee/per Registrant). If paying the total Fundraising Donation/per child/youth will be $309.30 per person (includes a $9.30 wire transfer fee per Fundaising Donation).
To Mail your registration to be received by October 15th, or pay online to secure your youth's space.
Mail To :
Trinity's Learning Resource Center
12725 W. Indian School Road, Suite E-101
Avondale, AZ 85392
To pay online through Paypal.com (a secured payment processing): There is a wire transfer fee automatically charged by Paypal.com for each entry. Please be sure to accurately calculate your total and note in the box that wire transfer fee below before making your payment.
Please select your payment option:
To make Registration/Fundraising Donation (see below). You will receive a tax deductible receipt for your charitable contribution. When making online payment, please note Student's Name in Notes/Comments Section.
Please select one:
For Registration ONLY:
For Registration & Fundraising Donations ONLY:
Important Note: Space is not guaranteed without online registration and registration fee paid. Please complete the online application if you have not already done so, and make payment above, or mail in your registration fee for each student enrolling in order to secure their space. Those who do not pay registration fee at time of online application (or by Orientation), will be placed on a waiting list.
Participation Authorization
A Desire to Succeed
Students must have the desire to be successful and be committed in every way possible to reach their life purpose, potential and goals in life. Student agrees to be cooperative, open, creative and will always be willing to participate in program activities. They commit to ask for help in order to obtain my goals. They will do everything to help in the success of their fellow classmates and the program. They agree to abide by the Learning Center’s rules and regulations.
Prayer
As a part of our program, we pray before and at the end of each class session. We believe that no man, family, or organization can be successful without the help [and aid] of God; drawing upon His Wisdom, strength, and insight. Therefore, we seek and ask the Lord’s blessing upon the class session and upon each student and family. We pray and intercede for individuals, families, and situations that students are concerned about so that all may receive God’s power to prosper and have good success. Although we pray, we are sensitive to and respect others who may not. No child will be made to feel they have to pray.
Approved Program Curriculum
Student’s curriculum and reading will include motivational and inspirational material that will help build esteem and confidence, help them to understand their purpose and potential, and help them to reach their life goals. This information contains biblical references, principles, and other quotes from scholars who are successful in different fields of life.
Photograph /Video Authorization
Trinity will take photographs to include your children strictly for program promotional purposes (newsletter, press releases, etc.).
Fundraising Agreement
As a Nonprofit organization, the Learning Center depends not only upon the financial contributions of the public and private sectors, but is also required to host fundraising programs of its own. Throughout the year, we will conduct fundraising activities such as Little Caesar's pizza & cookie dough sales, car wash, a family fun night (dinner & silent auction), etc. Participation is required for each student enrolled. As the parent/or student of age, you accept full responsibility to participate, encourage your child, and help them to complete the fundraising efforts, and to make sure that all monies are turned into the Learning Center on time. There are minimums required for each event fundraising event. Through Fundraising and sponsorship donations, each participant will raise a minimum of $250. (This is to help cover the costs for program class materials, incentives, graduation award jackets/sweaters & awards). Parents/students are responsible to sell all items required for each fundraiser, or become financially responsible (Example: Johnny is given 8 car wash tickets to sale at $5.00/donation each. Johnny must sell them or Johnny/Johnny’s parents become responsible for what was not sold.) This program becomes “no cost” if students/parents participate in fundraising programs as noted herein. All monies are due on the due dates as noted on the Fundraiser Instructions. If monies are not turned in as instructed, parents will be billed for the amount due, and payment is due upon receipt (and by next class time). For this reason, we strongly encourage you and your student(s) to actively participate in all fundraising activities and turn in the funds by the due date. Funds raised benefit your child in their life skills training and mentoring program and graduation, which is preparing them for successful living.
Program Fundraising Options:
1. Donate the full amount $300 ($50 Registration / $250 Fundraising Minimum) and receive a tax
deduction and deductible letter.
2. Participate in all fundraising activities and raise $250/per student; not tax deductible and
Parent/Student can request and obtain sponsorships from friends, family, co-workers, other
individuals, and businesses, etc. To print sponsorship forms to provide your potential sponsors, click
on the links below. All funds paid or donated toward Fundraising will receive tax deduction. All Sponsors
are publicly recognized at our graduation banquet.
Please select:
Note: Parents will be expected to fulfill their obligations.
Enrollment is conditioned upon agreement and authorization of the above. Complete all fields below:
* I/We (parents names)agree to
agree to participate and agree to give my child/youth (name of youth)
permission to participate in the program and will fulfill the fundraising requirements. This completed online application indicates your approval and commitment.
HEALTH CONDITION/MEDICATIONS (Please specify below):
Student History
All Fields must be complete by parent/guardian.
1. Does student currently participate in school activities? If so, please indicate.
2. Has student been involved in any disciplinary actions at school? If so, please explain.
3. Does student require special attention of any kind (example: learning disability)? If so, please explain.
4. Does student demonstrate desire for learning?
If Yes, explain.
5. What have you identified as being a key that motivates your child/youth to learn?
6. What hindrances do you identify in your child's/youth's education and development?
7.Describe your child's attitude toward the following areas of his/her life:
Describe your child's attitude toward the following areas of his/her life:a.Parents/Siblings –
Parents/Siblings – b.School/Instructors –
School/Instructors –c.Peers/Friends –
Peers/Friends –d.Future/Career –
Future/Career –8. How would you rate your child's overall attitude? (Check One)
9. What do you hope your child/youth receives or gets out of this program?
Note: Parents/Guardians will sign a release of for your child's report card at Parent Orientation.
Parent/Student Handbook
*Parents please read and review this Parent/Student Handbook with your child/youth and check the box below indicating that you have.
*Ethnic Survey (Please Check One)
*City:
*Present Address:
This page was last updated: October 22, 2010
NEW Youth Application
Trinity's Learning Resource Center, Inc.
"Providing Direction for the Next Generation,
Affecting Generations to Come, and Equipping Them For Successful Living"
12725 W. Indian School Rd., Suite E101
Avondale, AZ 85392
Phone (623) 512-4852
email: trinityslearningresource@yahoo.com
*Parent's Marital Status:
*Household Income:
*
*
*Total Household Members you are financially responsible for:
Parent Volunteering (Please select):
* Parent/Guardian's Cell:
Please complete an application for each child/youth that you will be enrolling.
After reading Parent/Student Handbook please check box below indicating you have received and read this handbook.
