Advanced Computer Science Program

Student Application

Hidden

Enrollment Site*

At which site is your child registered?

Child Name*

Parent / Legal Guardian Name*

Address*

Email*

Phone*

Child’s Ethnicity - Hispanic/Latino (a):*

Yes

Child’s Race*

FAMILY INFORMATION - A family is defined all persons living in the same household who are related by birth, adoption, marriage, or domestic partnership.*

Single Female Headed Family

Single Male Headed Family

Dual Headed Family

Number of persons living in your family?*

Total estimated income for next 12 months for all family members:*

SCHOOL ENROLLMENT:*

Child’s Gender*

Male

Female

Trans

Family Income - Select correct income level.*

1 - $29,100 - $48,550 - $77,650

2 - $33,250 - $55,450 - $88,750

3 - $37,450 - $62,400 - $99,850

4 - $41,600 - $69,300 - $110,900

5 - $44,900 - $74,850 - $119,800

6 - $48,250 - $80,400 - $128,650

7 - $51,550 - $85,950 - $137,500

8 - $54,900 - $91,500 - $146,400

Family Size, Extremely Low Income 30% of median, Very Low Income 50%, Moderate Income 80% of Median

Did your child participate in any other ELOC programs? Please check all that apply*

2021

2022

Never Attended Before

STUDENT CONSENT RELEASE

I now grant Environmental Leaders of Color, their successors, and their assignees the right to record the image and voice and use the artwork or written work of my child, on videotape, on film, on photographs, in digital media and any other form of the electronic or print medium and to edit such recording at their discretion.

I understand that my child’s full name, address, and biographical information will not be public. I further grant Environmental Leaders of Color, their successors, and assignees the right to use and allow others to use my child’s image or voice on the internet, in brochures, and any other medium and now consent to such use.

I now release Environmental Leaders of Color, their successors, and their assignees and any using my child’s image or voice, artwork, or written work according to this media release from any claims, damages, liabilities, costs, and expenses which my child or I now have or may hereafter have because of any use thereof.

I agree that the recorded image and voice and my child's artwork and written work belong to Environmental Leaders of Color and that my child or I will not get monetary compensation.

I understand that the provisions of this release are legally binding. Please check one:**

I don't consent

I consent

PARTICIPANT GROUND RULES

Environmental Leaders of Color (ELOC) is pleased to offer this advanced computer class to our high school students. You are guests of the SUNY Westchester Mount Vernon Extension site, and as such, it is a requirement that you adhere to a code of conduct. Environmental Leaders of Color (ELOC) reserves the right to dismiss student(s) who do not abide by these ground rules. 1. No eating or drinking in the computer lab. You may only eat and drink in designated areas. 2. Only enter classrooms, offices, or other approved sites with permission. 3. Do not download without permission. 4. Do not change the settings on the computer. 5. Ask permission to print documents. 6. Only access the computer lab with permission and if an ELOC-designated staff is in the room. 7. There is to be no inappropriate, unwanted, harassing, or sexual touching or conversations on the premises. 8. Disruptive behavior will not be tolerated. 9. All participants must carry school identification cards at all sessions. 10. Refrain from damaging the computers, equipment, or on-site facilities. 11. Please don't loiter on the premises before and after class. 12. Respect your classmates, instructors, ELOC, and site staff. 13. All students must sign in at all sessions. 14. In the case of an emergency, all students must follow the ELOC staff, site staff, and emergency personnel safety instructions.

Parent’s Signature:*

Student Signature:*