1
Student Information
2
Program Information
3
Consent for Participation and Release of Information
4
Emergency Contact Form
Full Name of Student:
*
Student's Name
Current Grade
*
Current Age
*
Sex
*
Male
Female
Ethnicity
*
Caucasian
Hispanic
African American
Asian
Multiracial
Select One
*
Alcohol-Related
Marijuana – Related
Tobacco Vaping/e-cig
Reason for Referral (Please give a short description)
*
Referral from (please check one)
*
School
Court
Self / Parent
Name of School
*
Arlington Tech
Career Center
Gunston
HB Woodlawn
Jefferson
Kenmore
Langston
New Directions
Swanson
Wakefield
Washington and Lee
Williamsburg
Yorktown
Other
If other, what school?
Name of person referring
*
Email
Confirm Email
Does the student speak and read English
*
Yes
No
If no, what language does the student speak?
Has the student been referred to/attended Second Chance before?
*
Yes
No
If yes, when?
Who referred him/her?
School
Court
Self/Parent
You will be contacted shortly by a Second Chance instructor to verify eligibility to attend the program a second time.
Parent/Guarding information
Parent/guardian name (1):
*
Parent/guardian (1) address/zip code
Parent/guardian name (2):
Address same as above
Parent/guardian phone:
*
Home:
Work:
Cell:
Parent/guardian email
Preferred way to reach parent/guardian (check the one that you will look at for important messages):
*
Email
Text to cell phone
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
Date
*
Printed Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
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
*
Title
Printed Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
Program Information
Please read the information below.
Dear Parent or Guardian, Welcome to the Second Chance Program. Our goal is to provide an educational experience that will help your child review his/her relationships, understand the harmful effects of using prohibited substances and what led him/her to do so, and change his/her behavior. Successful completion requires all three of the following.
3-Day Student Program
:
Your child is required to attend a 3-day early intervention, substance use education program. He/she will take the Substance Abuse Subtle Screening Inventory (SASSI) on Day Two of the program (more information regarding the SASSI can be found at:
www.sassi.com
).
When (Student Program)?
High School: March 11-13 - Student Program - Room 171
Middle School: March 18-20 - Student Program - Room 402
High School: April 22-24 - Student Program - Room 171
Middle School: May 6-8 - Middle School Student Program - Room 402
High School: May 13-15 - Student Program - Room 171
High School: June 10-12 - Student Program- Room 171
High School: July 1-3 - Student Program - Room 171
Select One -The session date at the top of the drop down list is the next available session.
Time:
8:45 a.m.-3:45 p.m. Arrive between 8:30 a.m and 8:40 a.m
Where:
Syphax Education Center,
Washington Boulevard, Arlington, VA
(Click here for directions)
.
Food:
Students must bring their own lunch. Water and snacks will be served.
Parent/Guardian Program
:
Parents/guardians are required to attend a 3-hour program during the week their child attends Second Chance:
When (Parent/Guardian Program)?
High School : March 13 - Parent/Guardian Program
Middle School: March 20 - Parent/Guardian Program - Room 441
High School: April 24 - Parent/Guardian Program
Middle School: May 8 - Parent/Guardian Program
High School: May 15 - Parent/Guardian Program
High School: June 12 - Parent/Guardian Program
High School: July 3 - Parent/Guardian Program
Select One -The session date at the top of the drop down list is the next available session.
Where:
Stambaugh Health Services Center (DHS), Lower Level, Room C, 2100 Washington Boulevard, Arlington, VA (entrance is directly across the street from the student program).
OR
When (Parent/Guardian Program)?
High School : March 16 - Parent/Guardian Program - Lower Level, DHS Building, Room C
March 20 - Parent/Guardian Program - Room 441
Middle School: March 23 - Parent/Guardian Program - Lower Level, DHS Building, Room C
High School: April 27 - Parent/Guardian Program - Lower Level, DHS Building, Room C
Middle School: May 11 - Parent/Guardian Program - Lower Level, DHS Building, Room C
High School: May 18 - Parent/Guardian Program - Lower Level, DHS Building, Room C
High School: June 15 - Parent/Guardian Program - Lower Level, DHS Building, Room C
High School : July 6 - Parent/Guardian Program - Lower Level, DHS Building, Room C
Select One -The session date at the top of the drop down list is the next available session.
Where:
Stambaugh Health Services Center (DHS), Lower Level, Room C, 2100 Washington Boulevard, Arlington, VA (entrance is directly across the street from the student program).
Food:
We provide some snacks and water. You are also welcome to bring your own.
Booster Session
:
You and your child are required to attend a follow-up booster session approximately 6 - 8 weeks after the 3-day program:
When:
Date to be confirmed at the parent/guardian session.
Time:
A 15-minute appointment between 6:30 p.m and 9:30 p.m. (specific time to be determined).
Where:
Stambaugh Health Services Center (DHS), Lower Level, Rooms B & C, 2100 Washington Boulevard, Arlington, VA (entrance is directly across the street from the student program).
Food:
We will provide pizza and water. You are also welcome to bring your own.
We look forward to working with you soon. Please let us know if you have any questions. Sincerely, Alvaro Alarcon Transitions…the Process for Change
Aalarcon_transitions@yahoo.com
202-644-6812.
Consent for Participation and Release of Information
Second Chance is a 3-day early intervention substance use education program provided in Arlington, Virginia. It is available to Arlington youth found in possession or under the influence of alcohol, marijuana, and/or certain other substances (for school referrals, “other substances” includes vaping). The educational components of the program help students review their relationships, understand the harmful effects of using prohibited substances and what led them to do so, and change their behavior. The program is held at the Syphax Education Center, 2110 Washington Boulevard, Arlington, VA. three consecutive school days from 8:45 a.m.-3:45 p.m.
Full name of your child
*
Student's Name
Click on the box below to select
*
I hereby give my consent for my child, to participate in the 3-day Second Chance Program and the subsequent Booster session.
Requirements for successful completion
:
Students must attend all three days of the student program and the follow-up Booster session, which is held approximately 6-8 weeks later.
Parents/guardians must attend a 3-hour parent/guardian program the week of the students’ program and the follow-up Booster session. Parents may attend on either Wednesday evening from 6:30-9:30 p.m. OR on Saturday morning from 9:00 a.m.-12:00 p.m. (unless otherwise noted). 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.
Students need to arrive between 8:30 and 8:40 a.m. and be prepared to start the session on time. 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 referral source or 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.
Students and parents/guardians must be respectful of the program facilitators and other participants at all times.
Students must not be under the influence or in possession of any substances or paraphernalia during any part of the program.
Students will not be able to use their phones or computers during the program. All phones 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 Alvaro Alarcon at: 202-644-6812.
Any infraction of these requirements,
including late arrival
, may result in dismissal from the program. If a participant is dismissed from the program for any reason, court and school consequences may be implemented.
Except as otherwise noted, my signature below indicates that I understand and agree with each of the following statements:
Participation in the Second Chance Program is strictly voluntary.
For school referrals
: I understand that my child will complete a Substance Abuse Subtle Screening Inventory (SASSI) and that the results will be shared with me, my child, the referral source, and the Substance Abuse Counselor at my child’s school.
For court and self-/parent referrals
Click on the box below to select
*
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 understand that, if my child does not adhere to the program and behavior requirements, he/she may be dismissed from the Second Chance Program. If this occurs, I will need to pick him/her up from the Syphax Education Center and he/she may be subject to school suspension or court involvement.
I further understand that if my child is dismissed from Second Chance and I am not able to pick him/her up from the Syphax Education Center, he/she may be returned to school via Red Top
Click on the box below to select
*
I have read the above terms, and I agree on behalf of myself and my child to 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 release and discharge Second Chance Arlington, the contracted instructors, and the Partnership for Children, Youth, and Families Foundation and its board members from and against all claims and losses of any type arising out of or relating to my child’s participation in the program.
Student
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
Date
*
Full Name of Student
*
Student's Name
Emergency Contact Form
Full Name of Student
*
Student's Name
Student’s Personal Contact Information:
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
*
Email
Confirm Email
Emergency Contact Information:
Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
Relationship
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Cell Phone
Work Phone
Email
Confirm Email
Medical Information:
Please send an email to Kelly Decker at: kdeckertransitions@yahoo.com and/or call: 703-278-2176 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:
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
Parent / Guardian Name
*
First
Last
Date
Parent / Guardian Name
First
Last
Developed by GEEKING OUT in NYC
© 2019 All rights reserved.
