The MOSES Program Inc. The MOSES Tutoring and Literacy Program www.mosesprogram.org mosesprogram@gmail.

com 267-664-1947 (Kendrah)/267-939-0624 (Felicia)

Completed paperwork is due upon registration. An Emergency Contact and Health Form and a Waiver and Release are included with this form.

Thank you for choosing the MOSES tutoring and literacy program. We are looking forward to an exciting academically enriching year with your child. Our FREE tutoring and literacy services as well as homework help are meant to assist your child with their homework as well as filling in possible gaps in their literacy and math. Below are some additional guidelines to help ensure that your child has a positive experience. We look forward to having a great experience with your child this 2012-2013 year. Student Drop-off: Park your car and escort your child or children to a staff person to confirm arrival on our attendance sheet at the check in/check out desk. Please be sure to sign your child in at the check in/check out desk as soon as you enter into the building Children may be dropped off no sooner than 15 minutes prior to the start of the program.

Student Pick-Up: Please pick up your child promptly at the end of the program. Please be sure to sign your child out at the designated check in/check out desk Anyone picking up your child that is not listed on the pick-up form will need to present a photo ID (i.e. drivers license) for release of your child We will not release your child unless proper identification is given to anyone other than a parent. Anyone authorized to pick up your child from camp, including yourself, should be listed on the Child Pick Up form. A copy of this form is included in this application. Please do not pick up a child without notifying staff. Personal Items: Please leave any electronic devices (ipods, ipads, Cd Players, mp3 players, game devices) at home for they will not be permitted into the program. Students will be allowed to bring a cell phone with them to the program but they must place the cell phone on silent and will only be permitted for use before or after the program or for emergency purposes ONLY.

Essential Eligibility Criteria: As a reminder, children must be able to do the following in order to participate in the program: Independently take care of their own personal needs (i.e. bathroom) Exhibit appropriate group behavior (doesnt disrupt the proper flow of teaching/learning) We require that all students participate in at least 2 community service activities hosted by the MOSES Program. This is outlined on this application.

Code of Conduct: Children are expected to demonstrate appropriate behavior at all times. Your child will be expected to: o Show respects to other program participants, tutors and other staff o Be pleasant to others and refrain from using foul or offensive language o Refrain from causing harm to themselves, other program participants or staff o Use equipment, supplies, and facilities properly and without causing damage or harm to items for camp use Discipline: If behavior issues arise during the program, the follow actions will be taken by teacher leaders and staff: Verbal warning Time Out: the child is removed from the particular activity for a time designated by tutors and staff Parent Involvement: if the child has difficulty controlling themselves after they have been in time out, the parent will be contacted to handle the situation. Removal from Program: if problems persist or the behavior is severe such as causing intentional harm to others or causing consistent disruptions of program activities, the child will be removed from the program for the day or the rest of the week. Depending on the severity of the infraction, the child may be removed PERMANANTLY from the program. Medical Issues: In the event of a medical emergency you will be notified immediately. You or your emergency contact need to be available to pick up your child from the program. These include student illnesses and severe injury. You will be notified in the event of any injury Medications: Children are expected to bring whatever medical supplies or medications (i.e.: epi-pen and asthma inhale) they will need time the program meets and turn it in to staff, along with written instructions. Staff will remind them to take medication if we are notified in writing about their schedule.

EDUCATIONAL FORM:
Specified Needs: Are you aware of any specific educational needs that your child may have? Could you describe what they may be below?

Educational Strategies: Are you aware of any specific educational strategies that have been utilized with your child at school or even at your home? Can you please describe below?

Additional Comments: Are there any other additional comments, questions, or concerns that you have regarding your childs educational needs?

EMERGENCY CONTACT AND HEALTH FORM:

Please fill out the following form and submit it on the day of registration. You can either email the form to the MOSES Program at mosesprogram@gmail.com, or drop the form off or mail to Berean Baptist Church, 2425 W. Indiana Ave, Philadelphia, PA 19138 including your payment for the two week program.

_________________________________ Name of student

_______/______/________ Date of Birth

_____________________ Entering Grade in School

____________________________ Street Address _________________________ Home Phone

Philadelphia, PA

_______________ Zip code _______________________ Parent(s) Name

___________________________ Cell Phone

______________________________________ School Child Attends

EMERGENCY CONTACT INFORMTION: ________________________________________ Emergency Contact Name __________________________________ Relationship to Student

_____________________________ Home Phone

_______________________ Cell Phone

_________________________ Email Address (if applicable)

Alternate Emergency Contact: ________________________________________ Alt. Emergency Contact Name __________________________________ Relationship to Student

_____________________________ Home Phone

_______________________ Cell Phone

_________________________ Email Address (if applicable)

CHILD PICK UP FORM: Anyone picking up your child will need to present a photo ID (i.e. drivers license) daily to program staff for release of your child. We will not release your child unless proper identification is given. Please list persons (including yourself) authorized to pick up your child. _______________________________________ Adult Name ____________________________________________ Adult Phone Number

_______________________________________ Adult Name

____________________________________________ Adult Phone Number

_______________________________________ Adult Name

____________________________________________ Adult Phone Number

You can also list a friend from the program that your child can travel with, please list the childs name and their parent (s) information: __________________________ Friends Name __________________________ Friends Parent(s) Name ________________________ Parent Phone Number

MEDICAL INFORMATION: Allergies or Dietary Restrictions: Please list below any food allergies or dietary restrictions that your child may have. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Are there any medications that your child must bring with him/her in order to participate in our program? If so, please list them below. (Please be aware that your child MUST be able to administer the medicine to themselves without the assistance of MOSES Program staff, yet we must be aware of medicine being administered) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

IMPORTANT INFORMATION:
The MOSES Program is committed to conducting its programs and activities in the safest manner possible and holds the safety of participants in the highest possible regard. Our students may participate in physical activities outdoors. The MOSES Program insists that all participants follow safety rules and instructions which have been designed to protect the participant's safety. Please recognize that the MOSES Program does not carry medical accident insurance for injuries sustained in its programs and activities. The cost of such medical expense would make program fees prohibitive. Therefore, each person registering themselves or a family member for a program or activity should review their own health insurance policy for coverage. It must be noted that the absence of health insurance coverage does not make the MOSES Program liable or responsible for any medical expenses. Your cooperation is greatly appreciated.

RELEASE OF LIABILITY:
I recognize and acknowledge that there are limited to no risks of physical injury to participants in the above program and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with the MOSES Tutoring and Literacy Program. I agree to waive and relinquish all claims I or my minor child/ward may have against the MOSES Program and its officers, agents, volunteers and employees as a result of participation in the program. I do hereby fully release and discharge the MOSES Program and its officers, agents, volunteers and employees from any and all claims from injury, damage or loss with the activities of the program. I further agree to indemnify and hold harmless and defend the MOSES Program and its officers, agents, servants and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program. In the event of any emergency, I authorize the MOSES Program to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered.

PHOTOGRAPHY RELEASE:
I hereby give permission that my child be photographed to be used in advertisements for the MOSES Program (i.e.: promotional materials, website, etc.) I have read and fully understand the above Release of Liability and Permission to Secure Treatment and Photography Release. ______________________________________________________ Signature of Parent(s) _________________________________________________ Printed Name of Parent(s) ___________________________ Date

M.O.S.E.S Student Mission Statement M.O.S.E.S. (motivating our students equipping scholars) is a non-profit organization that is dedicated to helping students achieve. The Mission for MOSES is to ensure that you, the student are prepared to pass any scholastic test and or assignment given. It is the programs mission to motivate you in such a way that you will be confident when you enter the classroom. The programs mission is to also equip you, the student, with the educational tools necessary to succeed in todays educational world. This means that as an M.O.S.E.S student you will work with tutors who are educated and knowledgeable of the subjects that you are studying and that M.O.S.E.S will provide the best materials and information to continue to equip you to become successful. Scholars are learned persons, especially an academic specialist in one area of knowledge. A student is a person, especially one who earns high grades This is the goal of M.O.S.E.S for each of its students. To become Scholarly students, those who enjoy learning and have an understanding of what they are learning. We want YOU to become life long learners who will become successful United States citizens.

M.O.S.E.S Student Code of Conduct & Contract By agreeing and signing this Code of Conduct, you the student agree to abide by its standards. I, ______________________________________, know that the MOSES program is a tutoring program that will provide educational services for me. I, _____________________________________, know that coming to the M.O.S.E.S program that I will turn OFF all electronic devices and leave them in my book bag or purse. This includes but is not limited to: cell phone, MP3 players, I pod, any device that is not being used by your tutor for educational purposes. I, _____________________________________, know that I must arrive on time (4:00 pm) or as close to that time, as weather permits. I know that arriving on time is important to my educational career. That any time that is wasted is time wasted from my learning and time that my tutor can use tutoring someone else. I, _____________________________________, know that I must refrain from using any foul or bad language while at the M.O.S.E.S program. I, ____________________________________, know that socializing with friends and others that are at the M.O.S.E.S program is for after the tutoring session (5:30 pm). I WILL NOT interrupt another student or tutor during their tutoring session to discuss matters that do NOT pertain to the tutor session. I, ________________________________, AGREE to bring copies of my daily reports, interims, report cards, test, project information and other EDUCATIONAL related material to the M.O.S.E.S program. I know that bringing these materials will be kept as confidential material discussed with the M.O.S.E.S directors, personal tutor and I. I, ________________________________, AGREE to allow the M.O.S.E.S directors to contact my school and parents as necessary to check on the progress of my educational career. I, ______________________________, AGREE to abide by and adhere to the standards set forth in this conduct agreement for the tutoring year.

___________________________________ Student Signature ___________________________________ Parent Signature

M.O.S.E.S Parent Contract

I, ______________________________________, the parent of _______________________________________, agree to allow M.O.S.E.S to provide tutoring services for my child for the calendar year ________________. I, ___________________________, also agree that M.O.S.E.S may call my childs school and contact teachers and/or counselors on behalf of my child, __________________________________. I, ___________________________________, the parent of _____________________________________, agree to provide copies of interims, report cards, behavior reports, IEP, etc. to the M.O.S.E.S program and know that these papers will be kept confidential and shared only with my childs tutor for educational purposes only. I, ________________________________ understand that the M.O.S.E.S program is NOT responsible for transporting my child to and from the tutoring program. Transportation is strictly the responsibility of me the parent. (* *exception: Prince Hall students will walk from Prince Hall to the M.O.S.E.S location upon dismissal of school, all Prince Hall students MUST have a way home or a walking partner.) I, _____________________________ also understand that the M.O.S.E.S program will require that as a parent, I attend two meetings per calendar tutoring year. I agree to attend said meetings or arrange a time to discuss my childs educational growth with the M.O.S.E.S directors. I KNOW that these meetings are designed to strengthen my childs connection with the program and overall educational career. I, ______________________________ AGREE to follow and abide by these standards to the best of my ability.

____________________________________ Parent Signature

_______________________ Date