LEARN Works Interest Intake Form

WELCOME

LEARN Works Interest Intake Form
Thank you for your interest in the LEARN Works programs at the Ada Jenkins Center. We are dedicated to supporting elementary students in our community through targeted academic assistance and providing a fun, safe, and enriching environment.

We offer three programs:
- LEARN Works Afterschool Academic and Enrichment Program (Free)
  This program focuses on students who are 1-2 grade levels behind in reading. Along with academic support, students enjoy activities such as career exploration, financial literacy, social-emotional learning, and parent engagement.
- LEARN Works After School Care Program ($50/week)
  This program provides a safe and engaging space for Kindergarten through 5th-grade students. It offers the same enrichment opportunities, even if the student is not behind in reading.
- Camp LEARN Works (Free, Summer Program) (Open Enrollment CLOSED)
  This summer camp is open to 1st through 5th-grade students, whether or not they are behind in reading. The camp refreshes reading skills while providing fun and enriching summer activities.
We look forward to supporting your child’s growth and success!
Before we get started, please answer the following question: Are you completing this form as:*

A referral from an educational facility (school, teacher, counselor, etc.)A parent/guardian interested in enrolling a student in a programMy child is re-enrolling in Learnworks
Will you be submitting applications for more than one student? Please note: This option is only for siblings or related student(s). Non-related students can be added at the "Thank You" page at the end. *
Which school year are you applying for?*
Note: For submissions of multiple students that are not related or siblings, a link is provided at the end of each form submission.
Parent Email*
example@example.com

Referring School/Facility
Referring Professional’s Name:

First NameLast Name
Title/Position:
(Teacher, Counselor, Principal, etc.)
School Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Please select the school you represent:
Other:

Previous Services:*

I have previously received services from the Ada Jenkins Center.This is my first time seeking assistance from the Ada Jenkins Center.
Program Options (Select all that apply): In addition to Learn Works

Food Pantry ReferralFree Tax PreparationClothing ReferralOther

Personal/Family Information

To ensure that we can accurately assess the eligibility and provide the appropriate support, please provide the following detailed personal/family information. All information will be kept confidential.
Agency ID Number
This is only for returning clients
Parent/ Guardian Name*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City*
State*
Zip Code*
Parent Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*
Ethnicity*
Race*
Marital Status*
Have you served in the military?
Income Information
What is your household size?*
What is your household's total annual income?*
(Select the range that applies to your household)

Student Information

Please provide the following information about the student who is interested in the LEARN Works program. Accurate and complete information will help us evaluate the student's eligibility and determine the best way to support their support their growth.
Which Learn Works Program are you interested in?*

After School Academic and Enrichment Program (Free)After School Care Program ($50/week)
Student Information*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Ethnicity*
Race*
School*
Other:
Race
Other:
School
Grade Level*
Please select the grade level for the upcoming year:
Does the student have learning accommodation?*
Can the student learn in an English only environment? *
The student needs to be able to understand and respond in English.
Additional Note(s)
Please provide additional information on special learning accommodations, or information that may be helpful to process the inquiry.

Student Information #2

Please provide the following information about the student who is interested in the LEARN Works program. Accurate and complete information will help us evaluate the student's eligibility and determine the best way to support their support their growth.
Which Learn Works Program are you interested in?

After School Academic and Enrichment Program (Free)After School Care Program ($50/week)
Student Information*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Ethnicity
Race
School
Grade Level
Can the student learn in an English only environment?
The student needs to be able to understand and respond in English.
Does the student have learning accommodation?
Additional Note(s)
Please provide additional information on special learning accommodations, or information that may be helpful to process the inquiry.

Student Behavior

Please answer the following questions related to the student’s behavior for whom you are applying. This section should be completed by a parent/guardian or a school representative. Answer each question by selecting a dropdown option:

	How would you describe the student's general behavior in school?	How often does the student interact positively with peers?	How would you rate the student's ability to follow instructions?	How would you describe the student's attendance at school?
Student #1
Student #2
Student #3
Student # 4

Academic Information

To better understand the student's academic performance, please provide the most recent assessment data below. If you do not have specific data, please enter "N/A."
Camp Learnworks

Please note the below information is not required for students applying to Camp Learnworks.

i-Ready Reading Placement

	Answer
Last Overall Placement (Grade Level):
Percentile:
Date of Last i-Ready Results:

Upload i-Ready Reading Placement*

Cancelof

DIBELS Results

	Answer
Last DIBELS Score:
Date of Last DIBELS Results:

Upload DIBELS Results

Cancelof

Other Recent Assessment Results: Please include any additional assessment results that provide further insight into the student's academic progress.

	Answer
Other Assessment Name:
Score/Outcome:
Date of Results:

Upload Assessment Information

Cancelof
Additional Information Upload

Upload all additional required documents here (e.g., Parental Consent Forms, etc.).
Upload all additional required documents here (e.g., Parental Consent Forms, etc.).*

Cancelof

Consent and Agreement

Thank you for providing the necessary information. Before proceeding, please carefully review the following sections regarding the release of your information, communication, and agreement to the program terms. Your consent ensures that we can coordinate services effectively and efficiently to meet your needs.
Release of Liability:
On behalf of myself and my household members, I hereby release and hold harmless The Ada Jenkins Center and its employees, agents, and partnering agencies from any and all liabilities, costs, or consequences related to the services provided, including but not limited to injury, death, damage, or loss of property. I understand that this agreement applies to any act or failure to act by The Ada Jenkins Center, its employees, or agents. I agree not to hold The Ada Jenkins Center or its employees or agents responsible for damages, and I will not pursue any legal action against them.

Purpose of Services:
I understand that the information provided by The Ada Jenkins Center and its partnering agencies is for educational purposes only and is not a substitute for expert consultation or advice. The services are intended to educate and inform families about resources such as financial literacy, employment skill-building, educational opportunities, life skills, and budgeting to strengthen families and promote stability.
I hereby agree to hold harmless and waive any rights or causes of action against The Ada Jenkins Center and partnering agencies for any financial or other damages resulting from the services provided.

Term of Agreement:
This agreement will remain in effect from the date of signing until my departure or the termination of the services provided.

Confidentiality and Data Consent:
I understand that my information will be kept confidential, and no information will be shared unless it is essential to assisting me. The Ada Jenkins Center will request my permission before releasing any information to partner organizations or other providers. Additionally, I authorize the entry of my information into The Ada Jenkins Center’s computer database. This consent is valid for one year and may be revoked at any time by submitting a written request.

Limits on Confidentiality:
- I acknowledge that certain situations require disclosure of confidential information by law. These include:
- If I am deemed a danger to myself or others.
- If a child under the age of 18 reports or is suspected of being a victim of abuse (physical, emotional, or sexual) or neglect.
Agreement and Acknowledgment:
By signing below, I confirm that I have read and understood the above information, and I have had the opportunity to ask any questions. I agree to the terms and conditions as outlined in this Consent and Agreement.
Authorization to Communicate via Text
I authorize the Ada Jenkins Center staff to send text messages to my mobile phone regarding my housing and assistance services. I understand that standard text messaging rates may apply based on my service plan.

I agree to receive text messages.I do not agree to receive text messages.
Certifications and AgreementBy signing below:

I certify that all information provided in this form is accurate and true to the best of my knowledge.I understand that a copy of this form may be shared with other entities as needed to verify eligibility for the Learnworks program or other services.
Date*

MonthDayYear
Date

Parental Engagement

At the Ada Jenkins Center, we believe that parental involvement plays a key role in a child’s success. To ensure the best outcomes, we ask parents or guardians to actively participate in their child’s educational journey through our LEARN Works programs. Please answer the following questions to help us understand your goals and level of commitment.
Are you willing to commit to the parental engagement requirements of LEARN Works? (LEARN Works requires regular communication with staff and participation in parent-focused activities.)
How would you describe your involvement in your child’s education?

Very involved (regularly help with homework, attend parent-teacher meetings, etc.)Somewhat involved (occasionally help, attend meetings when possible)Not very involved (find it challenging to participate due to other commitments)
In what ways can you support your child's participation in the program?

Attending family orientationVolunteering at LearnWorks events or activitiesParticipating in workshops or training to support my child’s learningRegularly communicating with LearnWorks staff about my child's progressParticipate in fun family engagement eventsOther

Attention:

Please take a moment to review the information you provided in the form. Once your form is submitted, someone from our team will review your submission. If we need any additional details, we will reach out to you directly.

We are excited about the possibility of working together to make a positive impact in our community and will be in touch with next steps soon.

Thank you again for your interest and support!

Best regards,
The LEARN Works Team
Ada Jenkins Center
Email
example@example.com
Should be Empty:

WELCOME

Referring School/Facility

Personal/Family Information

Income Information

Student Information

Student Information #2

Student Behavior

Academic Information

Camp Learnworks

Additional Information Upload

Consent and Agreement

Authorization to Communicate via Text

Parental Engagement