1
Student Information
2
Program Information
When: Select session (The date at the top of the drop down list is the next available student session).
June 28-30 - HS Session
Full Name of Student:
*
Student's Name
Student Phone
Student Email
Current Grade
*
Current Age
*
Gender
*
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 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
*
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?
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/Guardian 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
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
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:
*
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
*
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
*
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.
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. During Covid-19, all Second Chance sessions are being offered virtually. Students attend from 8 am to 12 pm on Monday and Tuesday.
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.
Parent / guardian name
*
Requirements for successful completion
:
All students must attend all four hours on both Monday and Tuesday, 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 2-hour parent/guardian virtual program the evening of Day 2, 6:30-8:30 pm. Information about the Booster session will be confirmed at the parent program.
No other children or parents are permitted to attend the student session.
No students or other children are permitted to attend the parent/guardian program.
Students must be connected via Zoom 5 minutes prior to the start of the session each day to ensure they are prepared to start on time. Parents are asked to do the same for their session, and both students and parents should plan to log on 5 minutes before their allotted time for the Booster session.
Students are expected to pay attention and participate fully at all times. This includes maintaining a webcam video and audio on for the duration of the session, unless instructed otherwise.
Students must use a laptop or desktop while attending the virtual Second Chance program. They are not to use a tablet or cell phone.
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 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.
If students are having issues logging in, they must contact 202-644-6812 as soon as possible to inform facilitators of what is going on so that they can help.
If a student is not logged in and ready to start the session within 15 minutes of the start time, the student will be dismissed from the program and will not be eligible to retake the program.
Participation in the Second Chance Program is strictly voluntary. However, any infraction of these requirements,
including being late to connect to the student, parent/guardian, or booster session
, may result in the student's dismissal from the program. If a student 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 that he/she may be subject to school consequences (including suspension) and/or court involvement.*
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
*
MM slash DD slash YYYY
Full Name of Student
*
Student's Name
Additional Comments/Questions
Please send an email to Miguel Alarcon at: miguel@impel.life and/or call: 707-805-6225 concerning any medical, behavioral, or other related issues that may make it difficult for your teen to participate fully.
Developed by GEEKING OUT in NYC
© 2020 All rights reserved.
