B.O.O.S.

T 2019-2020
START DATES: Sept30, 2019 through May 22, 2020
MONDAY - FRIDAY
Cleary 3:30-6:30 ~ BRMS 3:00 – 6:00
B.O.O.S.T 21​st​ CCLC Grant N.J.D.O.E.

STUDENT INFORMATION
PLEASE PRINT​:
Grade 8
Student Name: __________________________________ DOB:______________________ Grade:________

Address: _________________________________________________________________________________

__________________________________________________________________________________________

Phone#: _____________________________________ Cell#: ____________________________________

Buena Regional Middle School Male White

School: ___________________________________Gender: _____________Race: ______________________

Full Pay
Lunch Status (Choose One): _______ ​Free

Parent/Guardian Names: ___________________________________________________________________

Parent/Guardian Email: ___________________________________________________________________

Language Spoken at Home: ________________________________________________________________

1​st​ Emergency Contact Name: ______________________________________________________________

1​st​ Emergency Contact Phone#: __________________________________________________

2​nd​ Emergency Contact Name: ______________________________________________________________

2​nd​ Emergency Contact Phone#: __________________________________________________

 B.O.O.S.T 2019-2020
Buena Regional School District

Parent Agreement

● Students must attend ​at least​ ​3 days a week​. Please notify the BOOST office when your child will not
be attending the program.

● I will allow information regarding my child, while in the BOOST program, to be shared with the
LinchPin, LLC Grant Evaluators for grant evaluation purposes.

● Family involvement is highly encouraged.

● Parent/Student Handbook will be distributed on the first day of the program and must be reviewed,
signed, and the signature page must be returned.

● All forms ​MUST​ be filled out completely for your child to be accepted into the program. Your child
cannot start the program until you receive a welcome letter from the BOOST office.

I have read and agree to all the information provided on this form.

_________________________________________ ____________________________
Parent/Guardian Signature Date
 B.O.O.S.T 2019-2020
Buena Regional School District

Student Emergency Form

Grade 8
Student Name: ______________________________________ DOB:___________________ Grade: _______
Mailing Address:
__________________________________________________________________________________________
__________________________________________________________________________________________
Mother’s Name: ___________________________________________________________________________
Home Phone: ______________________Work: _______________________ Cell: _____________________
Father’s Name: ____________________________________________________________________________
Home Phone: ______________________Work: _______________________ Cell: _____________________

List two (2) relatives or neighbors who will assume temporary care of your child if you cannot be reached
within one (1) hour ​;

Name:_____________________________ Relationship:____________________ Phone: ________________

Name:_____________________________ Relationship:____________________ Phone: ________________

List any health problems, allergies, asthma, diabetes, epilepsy, heart conditions, eye or ear problems,
and/or all medications your child is taking. If none, please write “none.”
__________________________________________________________________________________________________
__________________________________________________________________________________________________
School policy requires all medications (prescription and nonprescription) shall only be administered in
school by a written order from the family physician and by written request of the parent/guardian. ​All

medications must be properly labeled in the original pharmacy container and brought to and from school
by the parent or guardian​. The physician must provide the school with a written order noting the name of

the drug, its dosage, the time at which it is to be given, and the diagnosis or reason for its use.
To serve your child in case of ACCIDENT or SUDDEN ILLNESS, it is mandatory that you furnish the
information requested on this form.
​Parent/Guardian Signature:________________________________________Date_____________________
 Buena Out Of School Time
21​st​ CCLC Grant Recipient
Site Address: 175 Weymouth Road, Buena, New Jersey 08310
Web site: www.buena.k12.nj.us
Phone (856) 697-0100 Fax (856) 697-9580

Melissa Finizio Mr. David C. Cappuccio, Jr. Karen Daigle

Director Superintendent of Schools Secretary
Ext: 6105 Ext: 5492

Pick Up Authorization Form

In past years, the B.O.O.S.T Program has made great strides in providing a safe and rewarding
experience for all students. In an effort to escalate security measures, please complete the form below
designating anyone (if any) you wish to grant the right to pick up your child from B.O.O.S.T. in your
absence.

It is important that you consider all possibilities in this matter. The B.O.O.S.T. program, upon receipt of
this form, recognizes the individuals listed below will be the ONLY people your child will be released to
should you be unable to personally pick up your child. The individuals you designate will be required to
present ​identification​ upon arrival and sign the release log prior to the child leaving the building.
​NO EXCEPTIONS WILL BE MADE​!

I, __________________________________________________, Parent/Guardian, authorize the following

(Please print)
individuals to pick up/sign out my child (listed below) from B.O.O.S.T. in the event that I will be unable
to do so. As the parent/guardian, I will make every effort to pick up my child personally, but if I am
unable to do so, please release my child to the following individuals only. I request that you check their
identification prior to releasing my child into their custody.

Students Name: _________________________________________________________

(Please print)

Approved people to pick up my child other than myself. Please print the names below;

1. _________________________________________________________________

2. _________________________________________________________________

3. _________________________________________________________________

4. _________________________________________________________________

_________ I choose NOT to designate anyone other than myself as a pick up person for my child from
B.O.O.S.T.. Please do not release my child to anyone other than myself.
Parent/Guardian Signature________________________________________Date______________________
 B.O.O.S.T 2019-2020
Buena Regional School District

Transportation Request

​Student Name: ____________________________________________________ Grade: ___________

Grade 8

Address: _____________________________________________________________________________
_____________________________________________________________________________

Nearest Cross Street: ______________________________________________________

Parent/Guardian Name: ___________________________________________Phone #:__________________________

EMERGENCY Contact Person: ______________________________________________________________________

EMERGENCY Contact Phone Number: _______________________________________________________________

STUDENTS IN GRADES 6​th​, 7​th​, 8​th​ ONLY:

As a safety precaution, students will not be permitted off the bus each evening unless a parent or guardian is
present. However, if you wish for your child to walk home from the bus without adult supervision, please
indicate below and sign:

I, _________________________________________________(parent/guardian) give permission for my child,

__________________________________________, to walk home from the bus stop without adult supervision.

Parent/Guardian Signature: __________________________________________Date:_________________

Do Not Write Below This Line (OFFICE USE ONLY)

STUDENT NAME: _________________________________________

STOP LOCATION: _________________________________________
BUS ROUTE NUMBER: ____________________________________
STOP TIME: ______________________________________________
 B.O.O.S.T 2019-2020
Buena Regional School District

Student Permission Slip for Field Trips

The B.O.O.S.T. program is sponsoring field trips throughout the school year to two different locations:
Regal Movie Theater in Vineland, and DiDonato’s Bowling Alley in Hammonton. The students will be
transported by buses. Departure and return times for the field trips will vary due to the travel time
associated with the location of the trips.

● If a student does not wish to participate in the trip activities, they are required to go home on
these days.
● Students who do not make the attendance requirement and/or break the discipline code will not be
allowed to attend the trips and are required to go home on these days.

PLEASE CHOOSE ONE​;

- OR -

Parent/Guardian Name:___________________________________________________
(Please print)

Parent/Guardian Signature: _______________________________________________

Date: __________________________
 B.O.O.S.T 2019-2020
Buena Regional School District

YMCA Student Permission Slip

I, __________________________________________ (Parent/Guardian) give permission for my child,

__________________________________________ , to participate in the YMCA component of the

B.O.O.S.T program. Students will travel by bus to and from the YMCA in Vineland, and will be escorted

by B.O.O.S.T staff. Students will have (1) hour of swimming instruction and/or water safety. All activities

will be conducted by trained YMCA professionals.

Parent/Guardian Name:______________________________________________________
(Please print)

Parent/Guardian Signature: ___________________________________________________

Date: ___________________________________

Is your child asthmatic? _________ If yes, can your child self administer? _______

Is your child diabetic? _______________

Does your child have allergies? (bee stings, food, etc.) ____________________________________________

Please specify any health related issues in the spaces provided below:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

B.O.O.S.T 2019-2020
Buena Regional School District

Student Permission Slip

Career Exposure at BRHS

I, ___________________________________________ (Parent/Guardian) give permission for my child,

____________________________________ to participate in attending Buena Regional High School during

the B.O.O.S.T program. Students will be walking to the high school and they will be escorted by

B.O.O.S.T staff. Students will be exposed to a vast number of different careers at the High School.

(The session dates for this portion of the program will be determined at a later time and will be posted on

the monthly B.O.O.S.T. calendars.)

_______ Yes, I give permission for my child to walk to and attend Buena Regional High School with the
BOOST program and staff.

_______ No, I do not give permission for my child to attend Buena Regional High School and I will not
send my child on the days the BOOST program is attending the high school.

Parent/Guardian Signature: _____________________________________Date: _______________________

 B.O.O.S.T 2019-2020
Buena Regional School District

Parental Consent Form for Release of Pupil Records

Student Name: ________________________________________________________________

(Please print)

I, ________________________________________________, (Parent/Guardian Name) give permission for

the BUENA REGIONAL SCHOOL DISTRICT BOARD OF EDUCATION to release my child's student
records, as specified below, to Linchpin LLC, for the purpose of conducting evaluation services as part of
the BOOST Program. I understand that this permission extends only to the parties specified above and
their agents, employees and/or representatives. I understand that these records shall not be disclosed,
furnished, used or reproduced for any purpose other than as provided in this Consent Form.

Records to be disclosed​:
Report Cards
Standardized Test Scores
Attendance records
Boost Discipline Records (if any)

Parent/Guardian Signature: ______________________________________Date: _____________________

 B.O.O.S.T 2019-2020
Buena Regional School District

Parental/Guardian Consent Form

(For use of student photos and/or other personal identifiers)

We are sending you this parental consent form to both inform you and to request permission for your child’s
photo/image and personally identifiable information to be published on the district and/or school’s web site.

As you are aware, there are potential dangers associated with the posting of personally identifiable information
on a web site since global access to the internet does not allow us to control who may access such information.
These dangers have always existed; however we, as schools, do want to celebrate your child and his/her work.
The law requires that we ask for your permission to use information about your child.

Pursuant to law, we will not release any personal identifiable information without prior written consent from
you as parent or guardian. Personally identifiable information includes student names, photo or image,
residential addresses, e-mail address, phone numbers and/or locations and times of class trips.

If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by
sending a letter to the principal of your child’s school and such rescission will take effect upon receipt by the
school.

Please choose ​ONE​ of the following choices (only one)​;

1.) _____ ​I/We GRANT permission for a photo/image that includes this student without any other personal
identifiers to be published on the school and/or district’s public internet site.

2.) ______ ​I/We GRANT permission for this student’s photo/image and name to be published on the school
and/or district’s public internet site.

3.) ______ ​I/We GRANT permission for this student’s photo/image and all other personal identifiers listed
above to be published on the school and/or district’s public internet site.

4.) ______ ​I/We ​DO​ ​NOT​ GRANT permission for photo/image that includes this student to be published
on the school and/or district’s public internet site.

Grade 8
Student’s Name ​(Please Print)​: ​_____________________________________________​ Grade ​__________

Parent/Guardian Name ​(Please Print)​: ​________________________________________________________

Parent/Guardian Signature:​ _______________________________________​Date:​___________________​_

 B.O.O.S.T. 2019-2020
Buena Regional School District

CODE OF CONDUCT

● All school rules are in effect during B.O.O.S.T. hours.

● When a student is written up a total of (3) times during BOOST and/or on the bus, they will be
dropped from the program.
● Student cell phones must be put away and on silent. If a student's cell phone is out, it will be
collected and brought to the office for parent pick up. If a student needs to make a phone call,
they can come to the office and use the phone.
● Disrespectful behavior towards a staff member and/or fellow students will not be tolerated.
● If the discipline referral is of a severe nature, the student(s) will be dropped immediately from
the program.
● Any student asked to leave the center on any given day will only be allowed back into the
program with permission from the B.O.O.S.T. administration.
● Suspension from school will result in automatic suspension from the B.O.O.S.T. program.
● Transportation home is considered part of the program. All students must follow the standards
of behavior while being transported home until the student is in custody of his or her
parent/guardian. If a bus driver deems it necessary to write your child up for a discipline
referral, the following will result:
1​st​ discipline referral - Warning – call home to parent
2​nd​ discipline referral - 1 day loss of bus privileges
3​rd​ discipline referral - dropped from program
● Fighting, swearing, verbal abuse, threatening, and/or hands-on behavior are not allowed at any
time and will result in the loss of a day (or more) from BOOST.
● Students must report to the cafeteria to their designated area immediately following dismissal
from school.
● All students must participate in cleaning up after an activity, and each student is responsible for
cleaning up after him or herself (returning materials, games, etc.).
● Students MUST attend at least 3 days a week​. Any student that does not attend on a regular
basis will not be permitted to participate in special events and/or trips, and may be removed
from the program.
● Students are recommended to wear sneakers on a daily basis during the program.

I have read and agree to follow all of the above stated rules.

*Student Name:____________________________________ ​(Please print)

Student’s Signature: __________________________________________ Date: ____________________

*Parent/Guardian Name:________________________________________ ​(Please print)

Parent/Guardian Signature: ____________________________________ Date: _________________

 Activity Permissions for B.O.O.S.T

I, __________________________, (parent/guardian) give my child ____________________________,

permission to participate in any activity that may have your child using equipment such as a microwave

oven, toaster, cutting utensils, different food products, hot plate, plastic cutlery and various food

ingredients, curling irons, blow dryers, flat irons, makeup, and makeup remover. An instructor will be

supervising all activities. If you have any questions or concerns please call the B.O.O.S.T Director,

Melissa Finizio at 856-697-0100, ext. 6105.

Please check off one:

_____ Yes, My child has permission to participate in the B.O.O.S.T activities.

_____ No, My child does not have my permission to participate in the B.O.O.S.T activities.

Parent Signature:________________________________________

Parent Name Printed:____________________________________ Date__________________________

Please list any food allergies that your child may have:
 B.O.O.S.T 2019-2020
* Important Dates to Remember *

Session 1​: ​September 30​th​- December 13​th

Session 1 dates that BOOST is closed;
October 14​th​, 16​th​ & 31​st
Week of November 4​th​ - November 11​th
November 21​st
Week of November 27​th​ - November 29​th
Week of December 16​th​ - December 20​th

Session 2​: ​January 2​nd​ - March 13​th

Session 2 dates that BOOST is closed;
January 20​th​ & 29​th
February 17​th
Week of February 24​th​ - February 28​th
Week of March 16​th​ - March 20​nd

Session 3​: ​March 23​rd​ - May 29​th

Session 3 dates that BOOST is closed;
March 25​th​, April 1​st
Week of April 6​th​ – April 13​th
May 1​st​ & May 25​th
**Last day will be May 29​th​**

❖ NO BOOST on early dismissal days.

❖ Please review your monthly calendars.

❖ Throughout the year, there may be additional days that BOOST will close, due to
budget restrictions and/or adverse weather conditions.

✔ Reminder​: Please see the school’s website for updates, program information and/or
any changes. The BOOST page can be found by clicking on the “District” tab, and
scrolling down to the BOOST page.