Electronic Referral - Second Chance

If the student speaks and reads English, please refer them to an English session.

1Student Information

2Program Information

3Consent for Participation and Release of Information

Consent for Participation and Release of Information
Student Information*
Student's Name
Click on the box below to select*
I hereby give my consent for my child, to participate in the Second Chance Program and the subsequent Booster session.
Requirements for successful completion:
- High School students must attend all three days of the student program (middle school students and those participating in the Spanish-speaking sessions must attend the full 2 days), and they and their parents/guardians must attend the follow-up Booster session, which is held approximately 6-8 weeks later.
- Parents/guardians must attend a 3-hour parent/guardian program, held from 6:30-9:30 p.m. on the last day of the student program (Day 3 for HS; Day 2 for MS/Spanish-speaking sessions), as well as the follow-up Booster session. Information about the Booster session time will be confirmed at the parent program.
- No students or other children are permitted to attend the parent/guardian program.
- High School students need to arrive between 8:15 and 8:25 a.m. and be prepared to start the session on time at 8:30 a.m. Middle school students and those attending the Spanish-speaking sessions need to arrive between 7:45 and 7:55 a.m. and be prepared to start the session on time at 8:00 a.m.
- Parents also must arrive on time for their program, and both students and parents should plan to arrive 5 minutes before their allotted time at the Booster session.
- Students and parents/guardians are responsible for their own transportation. If you cannot transport your child to the Syphax Education Center or otherwise arrange transportation for your child, please advise your school’s Assistant Principal.
- Students are required to bring their own lunch. Snacks and water will be provided.
- Students are expected to pay attention and participate fully at all times. This includes completing all in-class activities as well as staying awake during the entire session.
- Students must not be under the influence or in possession of any substances or paraphernalia during any part of the program.
- Students and parents/guardians must be respectful of the program instructors, guest speakers, and other participants at all times. Anyone showing disruptive behavior will be subject to dismissal from the program, resulting in the student’s unsuccessful completion.
- Students will not be able to use their phone, laptop, or any other electrical devices during the program. All devices will be placed in a basket upon arrival and returned when the students leave for the day. If parents need to reach their teen, they should contact Miguel Alarcon at: 703-344-8685.
- A student dismissed for disciplinary reasons will need to be picked up by a parent/guardian. On a case-by-case basis they may be returned to their school by Red Top Cab.
- Students will complete a Substance Abuse Subtle Screening Inventory (SASSI). For school referrals: I understand that the results will be shared with me, my child, the referral source, and the Substance Abuse Counselor at my child’s school.
Please check the box(es) below indicating your agreement to the following.*
- I give my consent for my child to participate in the Second Chance Program and the subsequent Booster session.*
- I understand that, if my child does not adhere to the program and behavior requirements, they may be dismissed from the Second Chance Program. If this occurs, I understand I will need to pick them up immediately from the Syphax Education Center. If I'm unable to do that I will let the notify the instructors.
- I have read the above terms, and I agree on behalf of myself and my child that we will abide by them for successful completion of the Second Chance Program as set forth by Arlington Public Schools and/or Arlington Juvenile Court, and the Second Chance provider, including participation in the Parent/Guardian program and the Booster session.*
- I agree on behalf of myself and my child that each of us releases, discharges and holds Second Chance Arlington, the contracted instructors, and the Arlington Foundation for Familes and Youth and its board members harmless from and against all claims and losses of any type arising out of or relating to my child’s participation in the program.*
Optional for court and self-/parent referrals:
- I give consent for Second Chance to contact the Substance Abuse Counselor at my child's school to notify him/her about this referral.
- I give consent for Second Chance to contact the Substance Abuse Counselor at my child's school to share the results of my child’s SASSI.

Emergency Contact Form
Full name of student*
Student's Name
Student address
Same as parent's

Street Address Address Line 2 City State ZIP Code
Emergency Contact Information:
Name*
Relationship to student*
Address*
Same as Page 1

Street Address Address Line 2 City State ZIP Code
Cell Phone*
Work Phone
Home Phone
Emergency contact email
Confirm emergency contact email
Medical Information:
Please send an email to Alvaro Alarcon at: alvaro@impel.life and/or call: 202-644-6818 concerning any medical issues including allergies, medications, health concerns, etc.
If your child needs to take any medication during the day, please indicate the name of the medicine, the dosage, and when it needs to be taken. The medication should be in the original container.
Please include below any additional information you want the instructors to know about your child (e.g., learning issues, difficulty paying attention, an IEP/504 accommodation, etc.) – or anything else that will help the instructors work with your child.
Consent*
- I am/we are the custodial parent(s)/guardians of the student named above. In my/our absence, we have left our child in the care of and do hereby authorize the instructors for the Second Chance Program to consent on our behalf to any emergency medical treatment that my/our child may require and I/we agree to bear financial responsibility for such care.
Date*
MM slash DD slash YYYY
Parent / Guardian Name*
Date*
MM slash DD slash YYYY
Parent / Guardian Name*

If the student speaks and reads English, please refer them to an English session.

Parent/Guardian Information

Signature of Parent/Guardian

Signature of Person Referring:

Consent for Participation and Release of Information

Emergency Contact Form

Emergency Contact Information:

Medical Information: