If the student speaks and reads English, please refer them to an English session.
1
Student Information
2
Program Information
3
Consent for Participation and Release of Information
When: Select session (the date at the top of the drop down list is the next available student session; if there is a bona fide reason the student should attend a session not listed below, please contact the instructors at: 202.644.6812).
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January 13-14, 2025 - Middle School Spanish Session
February 3-4, 2025 - Middle School Session
February 18-19, 2025 - High School Spanish Session
March 10-12, 2025 - High School Session
Student information
*
Student's name
Current grade
*
Current age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Ethnicity
*
Caucasian
Hispanic
AfricanAmerican
Asian
Arabic
Multiracial
Other
Have you attended Second Chance before?
*
Yes
No
Reason for the referral
*
Alcohol
Marijuana
Tobacco
Other
Please give a short description for the referral
*
Referral from (please check one)
*
School
Court
Self / Parent
Name of school
*
Career Center
Gunston Middle School
H-B Woodlawn
Thomas Jefferson Middle School
Kenmore Middle School
Langston HSC
New Directions
Swanson Middle School
Wakefield High School
Washington-Liberty (WL) High School
Williamsburg Middle School
Yorktown High School
Other
If other, what school?
Name of person referring
*
Email of person referring
*
Confirm email of person referring
*
Name of Substance Abuse Counselor
Email of Substance Abuse Counselor
Confirm Email of Substance Abuse Counselor
Does the student speak and read English?
*
Yes
No
Does the student speak and read Spanish?
*
Yes
No
If no, what language does the student speak?
Parent/Guardian Information
Parent/guardian name:
*
Parent/guardian address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Parent/guardian email
*
Confirm parent/guardian email
Parent/guardian cell phone:
*
Parent/guardian work phone:
*
Parent/guardian home phone:
*
Preferred ways to reach parent/guardian (check two):
*
Email
Call cell phone
Call home phone
Call work phone
Parent/guardian primary language
*
Will the parent/guardian need an interpreter?
*
Yes
No
Signature of Parent/Guardian
Is the parent present to sign this form?
*
Yes
No
Date
*
MM slash DD slash YYYY
Printed Name
*
First
Middle
Last
Click on box to select
Checking this box confirms that the parent has agreed to allow the referral source to check the box below on the parent's behalf.
Click on box to select
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
Signature of Person Referring:
Date
*
MM slash DD slash YYYY
Title
*
Printed Name
*
First
Middle
Last
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Emergency Contact Information:
Name
*
Relationship to student
*
Address
*
Same as Page 1
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
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