1
Student Information
2
Program Information
3
Consent for Participation and Release of Information
4
Emergency Contact Form
When: Select session (The date at the top of the drop down list is the next available student session).
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
Substance Abuse Counselor Email:
Confirm Substance Abuse Counselor Email:
Name of School
*
Career Center
Gunston
HB Woodlawn
Jefferson
Kenmore
Langston
New Directions
Swanson
Wakefield
W-L
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?
Date Format: MM slash DD slash YYYY
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
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Parent/guardian name (2):
Address for parent 2 same as above?
Yes
No
Does parent have an email?
*
Yes
No
Parent/guardian email
Address for parent 2:
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Confirm Parent/guardian email
Parent/guardian phone:
*
Home:
Work:
Cell:
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
Is the parent present to sign this form?
*
Yes
No
Date
*
Date Format: MM slash DD slash YYYY
Printed Name
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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
*
Date Format: MM slash DD slash YYYY
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
).
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:
The evening of Day 3 of the Student Program OR the following Saturday morning. Click
here
for the scheduled dates and times.
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.
You will receive a reminder phone call, text, or email a few days prior to the start of the student session. If you have any questions or concerns before then, please let me know. We look forward to working with you soon. 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 an 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. Middle school students attend two consecutive school days from 8:00a.m.-2:30p.m. and high school students attend three consecutive school days from 8:30 a.m.-3:15 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 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 evening of Day 3 of the Student Program or the following Saturday morning. Information about the Booster session 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.
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.
Participation in the Second Chance Program is strictly voluntary. However, 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, school consequences (including suspension) and/or court involvement may result.
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, he/she may be dismissed from the Second Chance Program. If this occurs, I understand I will need to pick him/her up immediately from the Syphax Education Center and that he/she may be subject to school consequences (including suspension) and/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 immediately from the Syphax Education Center, he/she may be returned to school via Red Top cab.*
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 Partnership for Children, Youth, and Families Foundation 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.
Is the student present to sign this form?
Yes
No
Click on box to select
Checking this box confirms that the student has agreed to allow the referral source to check the box below on the student's behalf.
Student
*
I understand that checking this box constitutes a legal signature confirming that all of the above information is true and accurate.
Date
*
Date Format: MM slash DD slash YYYY
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone
*
Cell Phone
*
Work Phone
Does the emergency contact have an email?
*
yes
no
Email
Confirm Email
Medical Information:
Please send an email to Alvaro Alarcon at: alvaro@impel.life and/or call: 202-644-6812 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
*
Date Format: MM slash DD slash YYYY
Parent / Guardian Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Parent / Guardian Name
*
First
Last
Additional Comments/Questions:
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