PLEASE KEEP THE FIRST 2 PAGES FOR YOUR INFORMATION
Application to Enroll in the
A’s & Aces Pathway to College After-school Initiative
for students (2nd – 3rd Graders)* Attending E. Hynes Charter School
Tuesdays and Thursdays 3:00-5:30PM
Application Procedures:
Fill in the attached application. This FULLY COMPLETED application (pages 3-7) is due on Friday, August 14, 2015
and must be returned to the Edward Hynes Charter School office. *Returning 4th graders may be accepted as well.
This Program begins on Tuesday August 18th 2015 and runs throughout the school year.
The A’s & Aces Pathway to College After-school Initiative is a tennis and academic/life-skills program. Children
spend half of the time on the tennis court (drilling, playing competitive games, and working on physical fitness)
and the other half in the classroom participating in our enrichment curricula (life-skills with focus on writing
and/or leadership building activities). Note that this is a structured student-athlete enrichment program for
younger participants and a student-athlete enrichment/leadership program for older participants; this is not
an after-care program.
Who is accepted to the A’s & Aces Pathway to College Program?
E. Hynes 2nd and 3rd (and returning 4th) grade students are eligible to apply. Students must be able to commit
to fully participate throughout the year on Tuesdays and Thursdays to be accepted. Spaces are limited and
only committed participants will be admitted to this program. Program selection criteria include:
behavior/sportsmanship, interest in competitive tennis, academic and athletic effort/ability, as well as
commitment by the student-athlete to the program’s high standards. Consistent attendance is required to
maintain a place in the Program.
How do students get to Dillard afterschool?
There are spaces available for Pathway to College participants to ride the school bus from Hynes to Dillard
University on Tuesday and Thursday afternoons right after school. Parents are responsible to pick up their
children at Dillard University promptly at 5:30. Any pick up after 5:45 will be assessed a $5 charge for each 15
min period or any part thereof.
What is the attendance policy?
Consistent attendance is a requirement. All absences must be excused. Upon the third unexcused absence, a
student may be dismissed from the program.
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What is the cost of the A’s & Aces Pathway to College Program?
There is a one-time fee for the entire year based on a sliding scale:
After-School Program fees per child are:
Annually
$240/child/yr
$160/child/yr*
$120/child/yr*
Regular fee:
Reduced fee:
Lowest fee:
* To be eligible for this discount, you must provide documentation of need, such as pay stubs or Snap award
letter (See scale below). Payment schedules available upon request, based on need. Please contact
Outreach@AsAndAces.org
The true cost to provide this program is much greater, and your true primary payment is your commitment to
attend for the full school-year. The fee must be submitted with the application by August 14th 2015 in order
for the application to be reviewed and your child considered for the program. The fee is refundable only if
your child is not accepted into the program. Checks should be payable to A’s & Aces.
What happens after I submit this application for my child? You will receive notification on Sunday 8/16/15,
via email. Students will then be added to the bus list heading to Dillard University on Tuesdays and Thursdays.
If you have questions please email F.HoffmanTerry@AsAndAces.org or Outreach@AsAndAces.org
Programing Start Date: August 18th 2015 (Tuesday)
FEE DETERMINATION
FOR USE BY A’S & ACES STAFF
This Federal Guide has been used by NORDC for determining camp fees and is used by A’s & Aces
generally for comparing income and household size, but is NOT necessarily determinative of program fee
categories.
As indicated by the applicant’s financial disclosure statement, mark the
Household Size box and select ONE of the 3 income options going
across on the same line.
Household Size
(Including Parents/
Guardians)
□1 Person
□2 Persons
□3 Persons
□4 Persons
□5 Persons
□6 Persons
□7 Persons
□8 Persons
2
May be
Qualified for
lowest
fee
□ 0-12,400
□ 0-14,150
□ 0-15,900
□ 0-17,650
□ 0-19,100
□ 0-20,500
□ 0-21,900
□ 0-23,300
May be
Qualified for
reduced
fee
□ 12,401-39,999
□ 14,151-54,999
□ 15,901-74,999
□ 17,651-99,999
□ 19,101-119,999
□ 20,501-139,999
□ 21,901-159,999
□ 23,301-179,999
Regular
fee
□ $40,000+
□ $55,000+
□ $75,000+
□ $100,000+
□ $120,000+
□ $140,000+
□ $160,000+
□ $180,000+
A’s & Aces Application
This FULLY COMPLETED Questionnaire must be received for consideration of your child’s enrollment. All data
are kept strictly confidential.
CHILD INFORMATION:
Full Name:________________________________________________________________
First
Middle
Last
Home Address:____________________________________________________________
Number & Street
Apt.
_______________________________________________________________________
City
State
Ethnic Background:
□Black/African American
□Asian/Pacific Islander
Gender:
□ Male □ Female
Zip
□White/Caucasian
□Multi-Racial
Grade:______
□Hispanic/Latino
□Native American/American Indian
Date of Birth:______________________
Primary Parent/Guardian (Parent/Guardian Filling Out Application):
Name:__________________________________________________________________________
First
Middle
Last
Address:________________________________________________________________________
Number and Street
Apt.
___________________________________________________________________________________________________
City
Zip
Employer: _______________________________________________________________________
Phones: Cell:_____________________________________________________________________
Work:___________________________________Home:__________________________________
Email:__________________________________________________________________________
Your Relationship to Student:
□ Mother □ Father
□ Grandparent
□ Relative
□ Foster Parent
□ Other: ________________
1. List any medical conditions we should be aware of (e.g., allergies, medication for ADHD)
______________________________________________________________________________________
______________________________________________________________________________________
2. Are you able to commit to the programming for the whole academic year?
Yes
No
Not sure
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Please list people besides parents or legal guardians who have permission to pick up participant
Name
Phone number
Relationship
1______________________________________________________________________________
2______________________________________________________________________________
3______________________________________________________________________________
Primary Caregiver Education:
Household Type:
□ No high school diploma
□ GED □ HS diploma
□ Technical or vocational school
□Some College/Associate degree
□ College Degree
□ Graduate Degree
□ Single Parent, female head of household
□ Single Parent, male head of household
□ Parent/Guardianship of Child
□ Two Parent Household
Please indicate any services the applicant or family receives:
□ Medicare
□ VA Benefits
□ Child Support
□ Social Security
□ Medicaid
□ Food Stamps
□ Unemployment
A’s & Aces Agreement
By signing below, I state that I understand the following rules:
●
●
I will ensure my child attends regularly. In the case of an absence, I will provide a written/email explanation in
advance within 24 hours of an anticipated absences and within 24 hours after an unanticipated absence.
My child will bring his/her own water container/squeeze bottle and wear tennis shoes and sports clothing.
I have read and understand the pick-up policies and understand that violations of program rules, including
unexcused absences, may result in dismissal.
__________________________________________
Print Parent’s Name
__________________________________________
Parent’s Signature
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________________________
Date
Applicant’s Household Financial Disclosure Statement
Parent/Guardian Information
Last Name: ________________________________________________ First Name: _________________________________________
Household size: circle the number of family members living in your household*
* Household means all person(s) who occupy a housing unit. The occupants may be single family, one person
living alone, two or more families living together, or any other group of related or unrelated persons who
share living arrangements.
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2
3
4
5
6
7
8
Over 8
Gross income and ethnicity (check the space in columns that most accurately describes your
household):
GROSS INCOME
______$ 0.00 -34,300.00
______$34,301.00 – 39,200.00
______$39,201.00 - 44,100.00
______$44,101.00 -48,950.00
______$48,951.00 - 52,900.00
______$52,901.00 - 56,800.00
______$56,801.00 - 60,700.00
______$60,701.00 -64,650.00
______$64,651.00 -74,650.00
______$74,651.00 -84,650.00
______$84,651.00 -94,650.00
______$94,651.00 -104,650.00
______ $104,651 – 114,650
______ $114,651 – 124,650
______$124,651 – 134,650
______$134,651 – 144,650
______$144,651 – 154,650
______$154,650 – 164,650
over $164,651.00
ETHNICITY
______ Black/African American
______ White/Caucasian
______ Black/ African American & White
______ Hispanic/ Latino
______ Asian
______ Asian & White
______ American Indian/ Alaskan Native
______ Pacific Islander/ Native Hawaiian
Household type (circle the best description of your household):
____ Single Parent, female head of household
____ Single Parent, male head of household
____ Two Parent Household
____ Parent/Guardianship of Child
I certify that all of the information provided herein is true and correct and that all household income is
reported.
Parent/Legal Guardian Signature: ____________________________________________________ Date: _______________
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A’s & Aces
PLEASE PRINT:
Child’s Name:
Parents’ or Guardians’ Names:
Parent/Guardian Emergency Phone numbers:
Parent Permission, Waiver and Release Form
I/We, the parents/guardians of _________________________________, understand the nature and purpose of the
training and instruction planned. We declare that the above named student is of sound physical condition for instruction
and training in tennis or exercise classes, making no declaration to the contrary to A’s & Aces or its partners. We grant our
son/daughter permission to participate in these in-school /after-school academic/life skills/tennis activities.
We agree to waive all rights, release and hold harmless A’s & Aces, Dillard University, their boards of directors, officers,
partners, agents, employees, service-learners and volunteers, from any and all liability, claims, suits, demands, judgments,
costs, interest, and expenses (including attorneys’ fees and costs) of any kind arising from or related to such activities,
including any accident or injury to our child or myself and the costs of medical services. A’s & Aces does not provide
student accident insurance coverage for students while participating in the A’s & Aces program.
In the event of an injury requiring medical attention, we grant permission to the supervising party (including volunteers) to
attend to our son/daughter. If the injury warrants further medical attention, we give our permission to the supervising party
(including volunteers) to take our child to a physician, dentist, or hospital if deemed necessary and we accept financial
responsibility for all such medical attention.
We give A’s & Aces and its partners the absolute right and permission to use our son’s/daughter’s photograph or
videography in promotional materials and publicity efforts. We understand that the photographs may be released to
newspapers and may be used in other publications, as printed as, direct-mail, electronic media, or other forms of
promotion. We further release A’s & Aces, its partners, photographers, and their agents from liability for any violation of
any personal or proprietary right we may have in connection with such use.
We understand that information contained in my child’s school record is confidential. However, we give permission to my
child’s school and its administrators to provide access and release to A’s & Aces school records relating to my child,
specifically including but not limited to all report cards and other academic, attendance and behavior information, to allow
best opportunities to assist my child and to compile and evaluate data relating to school and program efficacy. This
consent is subject to my written revocation at any time except to the extent that action has already taken place upon this
consent. A copy of this consent should be accepted with the same legal authority as the original.
___________________________________________
__________________________
Signature of Parent or Guardian
Date
____________________________________________________
_____________________________
Signature of A’s & Aces Representative
1036 Arabella, New Orleans, LA 70115 • (504) 895-9933
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Date
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