Thank you for your interest in enrolling your student in the ABC to PhD Saturday Enrichment Academy, powered by the Southern Nevada Black Educators Initiative (SNBEI) and Nevada Partners. This program is designed to enhance literacy, math, and science skills for Pre-K-3 students in a supportive and engaging environment. Please complete this form to provide the necessary information and to acknowledge our policies and waivers. This program is offered at no cost to the community, but space is limited, and enrollment will be on a first-come, first-served basis. Submission of this form does not guarantee a spot in the program. We look forward to supporting your student’s academic journey and partnering with you to create a pathway from their ABCs to PhDs! Student Information * First Name * Last Name Date of Birth * MM DD YYYY Gender * Female Male Other Prefer Not to Say Race/Ethnicity * (For demographic purposes only. This information helps us better understand and serve our students.) Black or African American Hispanic or Latino/a/x Asian or Asian American Native Hawaiian or Other Pacific Islander Native American or Alaska Native White Middle Eastern or North African Multiracial or Two or More Races Prefer not to answer Grade Level * Please select the grade the student will begin in August 2025. 3rd Grade 2nd Grade 1st Grade Kindergarten Pre-School Did your child participate in cohort 3 of the ABC to PhD Saturday Academy? * Yes. my child participated in AND successfully completed Cohort 3. Is the student enrolled in the Clark County School District? Yes No School Attending * Parent/Guardian/ Care-Taker Information First Name Last Name Relationship to Student * Phone * Country (###) ### #### Email Address * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Information * First Name Last Name Relationship to Student * Phone * Country (###) ### #### Alternative Authorized Pick-up Person * Last Name First Name Last Name Phone (###) ### #### Eligibility Requirements * To participate in the program, children must meet the following requirements: 1. Be at least 4 years old by the program start date. 2. Be fully potty trained prior to attendance. Eligibility Confirmation: Yes, my child meets the age and potty training requirements. Program Schedule & Cohort Selection * Cohort 4: Saturday, September 13th- Saturday, November 1st 26th Mandatory Family Information Session Acknowledgment * I understand that myself or a family representative is required to attend the virtual Mandatory Family Information Session on Saturday, August 16th from 4:00–5:00 PM in order for my child to participate in the program. Yes, I confirm that myself or a family representative will attend the session. Health & Safety Information Does your child have any food allergies? * No Yes Food Allergies Does your child have any medical conditions or special needs we should be aware of? * No Yes (Please specify) Medical Conditions Does your child have an Individualized Education Program (IEP)? * No Yes (Please provide details and upload a copy if available): Does your child have a Section 504 Plan? * No Yes (Please provide details and upload a copy if available): Please describe any specific accommodations or modifications your child requires to participate fully in the program: * If this does not apply to your child, please enter "N/A." Does your child require medication during the program? * No Yes (Please specify): Specify any Medications Needed During Program Hours Primary Care Physician * Phone (###) ### #### Safety Waiver and Consent * By signing below, I, the parent/guardian/care-taker of the student listed above, agree to the following: 1. Assumption of Risk: I acknowledge that participation in the ABC to PhD Saturday Academy involves various activities and interactions, which may carry inherent risks, including exposure to illnesses or communicable diseases. I understand that while SNBEI takes reasonable precautions to ensure a safe and healthy environment, it cannot guarantee that my child will not be exposed to illnesses, including those potentially resulting from being unvaccinated. 2. Release of Liability: I release the Southern Nevada Black Educators Initiative (SNBEI), its staff, volunteers, and partners from liability for any injuries, illnesses, or incidents that may occur during the program, except in cases of gross negligence or intentional misconduct. 3. Emergency Medical Consent: In the event of an emergency, I authorize SNBEI staff to take necessary action, including seeking medical treatment for my child, until I can be reached. I understand that I will be responsible for any medical expenses incurred. 4. Acknowledgment of Program Policies: I understand and agree to comply with all program policies, including health and safety guidelines, and will promptly notify SNBEI of any changes to my child’s health status, including exposure to communicable diseases. 5. Personal Belongings: I agree that SNBEI is not responsible for any lost or stolen personal items during the program. Yes, I agree No, I do not agree Signature * Full Name Date MM DD YYYY Program Agreement * By enrolling my child in this program, I understand and agree to: 1. Provide accurate information on this form. 2. Failure to pick up your child at the designated time may result in a $25 fee for every 30 minutes past the scheduled pick-up time and/or removal from the program. 3. Communicate promptly with SNBEI about any changes to my child’s health or availability. 4. Commit to bringing your child every Saturday. Failure to do so will result in a dismissal from the program. Yes, I agree No, I do not agree Photo/Video Release * By enrolling my child in the ABC to PhD Saturday Academy, I acknowledge that photos and videos may be taken during program activities for educational, marketing, and promotional purposes, including but not limited to ClassDojo, social media, websites, and other program-related materials. I understand that these images and recordings may be used to highlight the impact and success of the program and that by signing this enrollment application, I grant permission for my child’s image to be used accordingly. First Name Last Name Signature Full Name Date MM DD YYYY Text * FIrst Name Thank you for completing the application for the ABC to Ph.D. Saturday Enrichment Academy! We appreciate your interest in this transformative program, powered by the Southern Nevada Black Educators Initiative (SNBEI) and Nevada Partners.
