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Enroll for Springboard:

Yes, I want to enroll. Si, quiero inscribirseYes, I want to enroll. 是的，我想報名。

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Deactivated enrollment form?

YesNoClosed

Page 2

Enrollment is currently closed for your school.

La inscripción está cerrada para su escuela.

Enrollment is currently closed for your school.

您所在學校的註冊目前已關閉。

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Child Information

Check here to confirm that you are over 18 years of age and that you are a parent, family member, or caretaker with authority to enroll your child.

Has your child participated in Springboard before?

YesNo

Child's First Name:

Child's Last Name:

My child's date of birth (mm/dd/yyyy):

*We only use this info to uniquely identify your child in our database

My child's gender is:

MaleFemaleNon-binaryPrefer not to say

Is your child's ethnicity Hispanic or Latino?

YesNoPrefer not to say

My child's race is:

Asian	Black or African American
American Indian or Alaska Native	White
Native Hawaiian or Other Pacific Islander	Other
Prefer not to say

Other race or origin:

Does your child/student receive Special Education services (IEP and/or 504 Plans)?

YesNoI don't know
Prefer not to say

Please share any detail about the IEP/504 Plan your student has that you would like for us to pass onto your child's teachers.

Please note that this information will be used to improve the equity of program experiences for all students.

Does your child receive ESL/ESOL/ELL (English Language Learner) services?

YesNoI Don't KnowPrefer Not to SayOtherPlease note this information will not alter the program for your child. It will be used to improve program experiences for all students in the future.

If you selected 'Other', please provide further explanation:

Name of your child's school:

Start typing the name of your child's school or your city. When the name appears, select it from the dropdown. If you do not see your child's school, select "Other".

Season

If your school did not appear in the list above, check this box.

My school is not listed

Name of the district/network:

Full name of school your child attends:

Student ID number:

Student's district- or school-provided ID number, if applicable

What grade was your child enrolled in during the previous school year?

PreK/TK	Kindergarten
1st	2nd
3rd	4th
5th	6th
7th	8th

What grade is your child enrolled in during the current school year?

PreK	Kindergarten
1st	2nd
3rd	4th
5th	6th
7th	8th

What grade was your child enrolled in during the previous school year?

PreK	Kindergarten
1st	2nd
3rd	4th
5th	6th
7th	8th

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Parent / Guardian Information

First Name:

Last Name:

Phone:

Email:

IMPORTANT: Please provide an accurate email address so that you can receive digital programming rewards if your child is eligible

Additional Guardian's Phone:

Additional Guardian's Email:

Street Address:

City:

State:

Zip Code:

At home, our family mostly speaks:

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Agreement to have Springboard Use Your Child's Image, Audio and First Name

YesNoSometimes we request photos of teachers and students in action to show our program at work! In a virtual world, photos might include a screenshot of a zoom class or of a celebration at the end of the program. In person photos might include students reading independently, with their parents or with their teachers. These photos are usually used for data reporting, future funders and/or for promotional materials about Springboard. The only identifying information would be the child's first name but nothing else (i.e. not their last name, address, etc.).

Agreement for Springboard to Text You

YesNo

Agreement for Data Use

I give Springboard permission to use the information from this form and from my family's participation in this program to (1) ensure that I can engage in the program (i.e. collect my family's attendance and student's assessment data) and (2) report on the results of this program. I understand that Springboard will remove all information that identifies my family when doing that reporting, such as our names or contact information.

Similar to the media release, school partners and funders typically ask for reports from previous partnerships to see how it went. The data we share is never identifying individual students; rather it includes demographic information about them, such as grade, ethnicity, gender and assessment data/reading level if available. This information would never identify a child like "John Brown at School ABC has an IEP and is reading on a level G." Rather, it could sound like "John, a 3rd grade boy, grew from a Level G to a Level P in F&P after completing Springboard this spring." It could be even more broad like "x% of Hispanic students attended Springboard programming at School ABC."

Parent Agreement

Would you like to be contacted with future opportunities to share your feedback and suggestions to improve our programs?

YesNo

This program is funded through the Office of the State Superintendent of Education (OSSE). I hereby consent to Springboard Collaborative securely releasing personally identifiable information from my child's education records (including enrollment, attendance, assessment data, and qualitative feedback) to the OSSE.

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Información básica del estudiante

Marque aquí para confirmar que es mayor de 18 años y que es un padre, un familiar o un cuidador con autoridad para inscribir a su hijo.

¿Ha participado su hijo en Springboard antes?

SíNo

Nombre de mi hijo/a:

Apellido de mi hijo/a:

La fecha de nacimiento de mi hijo/a:

El género de mi hijo/a:

masculinofemeninoNo binarioPrefiero no hacerlo

¿El origen étnico de su hijo es hispano o latino?

SíNoPrefiero no decir

La raza de mi hijo/a:

Afroamericano	Caucásico
Asiático	Nativo americano
Nativo hawaiano u otro isleño del Pacífico	Otro
Prefiero no hacerlo

Otro:

¿Recibe su hijo/estudiante servicios de Educación Especial (IEP y/o Planes 504)?

Sí

No sé

Prefiero no decirlo

Comparta cualquier detalle sobre el Plan IEP/504 que tiene su estudiante que le gustaría que transmitimos a los maestros de su hijo.

Tenga en cuenta que esta información se utilizará para mejorar la equidad de las experiencias del programa para todos los estudiantes.

¿Su hijo/estudiante recibe servicios de ESL/ESOL/ELL (Aprendiz de la lengua inglesa)?

Sí

No
No séPrefiero no decirloOtroTenga en cuenta que esta información se utilizará para mejorar la equidad de las experiencias del programa para todos los estudiantes.

Otro:

¿A qué escuela asiste actualmente su hijo?:

Empiece a teclear el nombre de la escuela de su hijo, o de su ciudad. Cuando aparece el nombre, selecciónelo del desplegable. Si no ve el nombre de la escuela de su hijo, seleccione "Other".

Season Spanish

Si Ud. seleccione "Other" en la lista, seleccione esta caja

Mi escuela no está en la lista

Nombre del distrito / red:

¿A qué escuela asiste actualmente su hijo?

Número de estudiante:

¿En qué grado estaba matriculado su hijo durante el año escolar previo?

PreK/TK	Kindergarten
1o	2do
3ro	4to
5to	6to
7to	8to

¿En qué grado está su hijo durante el año escolar actual?

PreK/TK	Kindergarten
1o	2do
3ro	4to
5to	6to
7to	8to

¿En qué grado estaba matriculado su hijo durante el año escolar previo?

PreK/TK	Kindergarten
1o	2do
3ro	4to
5to	6to
7to	8to

Página 2 de 3

Información de padre/tutor

Nombre:

Apellido:

Correo Electrónico:

IMPORTANTE: Por favor, proporcione un email correcto para que pueda recibir recompensas digitales de programación si su hijo es elegible.

Celular:

Otro Número de Teléfono:

Otro Correo Electrónico:

Domicilio

Ciudad

Estado

Código postal:

En casa, mi familia y yo principalmente hablamos:

Página 3 de 3

Lanzamiento de prensa

Concedo el permiso para que cualquier fotografía, imagen, voz, video, o alguna otra grabación, en toda forma, y también que el primer nombre de mi hijo/a sea publicado o distribuido en cualquier medio con fines promocionales o informativos en conexión con Springboard Collaborative.

SíNo

Comunicación de Springboard

Acepto recibir mensajes de texto de Springboard Collaborative, incluyendo recordatorios de talleres, recordatorios de lectura y consejos de Springboard Connect, y encuestas. Puedo dejar de recibir estos mensajes en cualquier momento enviando mensajes de texto STOP. Acepto Connect Terms and Conditions and Privacy Policy.

SíNo

Lanzamiento de datos

Autorizo a Springboard a utilizar la información de este formulario y de la participación de mi familia en este programa para (1) garantizar que pueda participar en el programa (es decir, recopilar la asistencia de mi familia y los datos de evaluación del alumno) y (2) informar sobre los resultados de este programa. Entiendo que Springboard eliminará toda la información que identifique a mi familia al hacer ese informe, como nuestros nombres o información de contacto.

Permiso del padre

Entiendo la naturaleza del Programa de Springboard Collaborative y también entiendo que la participación en el programa es voluntaria. Entiendo que Springboard Collaborative no es responsable por la pérdida, daño, enfermedad o lesiones a personas o propiedades como consecuencia de la participación en el programa. Yo libero y descargo Springboard Collaborative y sus funcionarios, empleados, agentes y voluntarios de cualquier y todas las reclamaciones por lesión, enfermedad, muerte, pérdida o daño como resultado de las actividades del programa.

¿Le gustaría ser contactado con futuras oportunidades para compartir sus comentarios y sugerencias para mejorar nuestros programas?

SíNo

Este programa está financiado por la Oficina del Superintendente Estatal de Educación (OSSE). Yo por la presente consiento a que Springboard Collaborative, de forma segura, divulgue información personalmente identificable del expediente escolar de mi hijo (incluyendo matrícula, asistencia, datos de evaluación, y retroalimentación cualitativa) al OSSE.

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Child Information 小孩信息

Check here to confirm that you are over 18 years of age and that you are a parent, family member, or caretaker with authority to enroll your child.在此處檢查以確認您已年滿 18 歲，並且您是有權為您的孩子報名的父母、家庭成員或看護人。

Has your child participated in Springboard before? 您的孩子以前參加過Springboard嗎?

Yes 參加過No 沒有參加過

Child's First Name 孩子的名:

Child's Last Name 孩子的姓:

My child's date of birth (mm/dd/yyyy) 孩子的出生日期（mm / dd / yyyy）:

*We only use this info to uniquely identify your child in our database

My child's gender is 孩子的性別:

Male 男Female 女Non-binary 非男非女Prefer not to say 不想說

Is your child's ethnicity Hispanic or Latino? 您孩子的種族是西班牙裔還是拉丁裔？

Yes 是No 否Prefer not to say 選擇不説

My child's race is 我孩子的種族[選擇所有適用項]:

Asian 亞裔	Black or African American 黑人或非裔美國人
American Indian or Alaska Native 美洲印第安人或阿拉斯加原住民	White 白人
Native Hawaiian or Other Pacific Islander 夏威夷原住民或其他太平洋島民	Other race or origin 其他種族或血統
Prefer not to say 不想說

Other race or origin 其他種族或血統:

Does your child/student receive Special Education services (IEP and/or 504 Plans)?

您的孩子/學生是否接受特殊教育服務（個別教育計劃 (Individual Education Program, IEP) 和/或 504 計劃）？

Yes 是 No 否 I don't know 我不知道 Prefer not to say 選擇不説

Please share any detail about the IEP/504 Plan your student has that you would like for us to pass onto your child's teachers.

請與我們分享您的學生接受的 IEP/504 計劃的任何詳情，我們會將這些資訊告知您孩子的教師。

Please note that this information will be used to improve the equity of program experiences for all students. 請注意，此信息將用於提高所有學生的課程體驗的公平性。

Does your child receive ESL/ESOL/ELL (English Language Learner) services? 您的孩子/學生是否接受 ESL/ESOL/ELL（英語學習者）服務？

Yes 是No 否I don't know 我不知道Prefer not to say 選擇不説Other 另Please note that this information will be used to improve the equity of program experiences for all students. 請注意，此信息將用於提高所有學生的課程體驗的公平性。

Other 另:

Name of your child's school 您孩子就讀學校的名稱:

开始输入您孩子所在学校的名称或您所在的城市。当名称出现时，从下拉列表中选择它。如果您没有看到您孩子所在的学校，请选择“其他”。

Season Chinese

If your school did not appear in the list above, check this box. 如果您的學校沒有出現在上面的列表中，請勾選這個框。

My school is not listed

我的學校不在名單上

Name of the district (eg Oakland Unified School District)

地區名稱:

Full name of school your child attends (eg Patrick Henry Elementary School)

您孩子就讀學校的全名:

Student ID number 學生號碼:

What grade was your child enrolled in during the previous school year? 您的孩子在上一學年就讀於哪個年級？

PreK/TK 學前班/過渡幼稚園	Kindergarten 幼稚園
1st 一年級	2nd 二年級
3rd 三年級	4th 四年級
5th 五年級	6th 六年級
7th 七年級	8th 八年級

What grade is your child enrolled in during the current school year? 對於學年參與者，您的孩子在當前學年就讀於哪個年級？

PreK/TK 學前班/過渡幼稚園	Kindergarten 幼稚園
1st 一年級	2nd 二年級
3rd三年級	4th 四年級
5th 五年級	6th 六年級
7th 七年級	8th 八年級

What grade was your child enrolled in during the previous school year? 您的孩子在上一學年就讀於哪個年級？

PreK/TK 學前班/過渡幼稚園	Kindergarten 幼稚園
1st 一年級	2nd 二年級
3rd三年級	4th 四年級
5th 五年級	6th 六年級
7th 七年級	8th 八年級

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Parent / Guardian Information 家長/監護人信息

First Name 名:

Last Name 姓:

Phone 電話:

Email 電子郵件:

重要資訊：請提供準確的電子郵件地址，以便在您的孩子符合資格條件時接收數字程式獎勵。

Additional Guardian's Phone 附加監護人電話:

Additional Guardian's Email 其他監護人的電子郵件:

Street Address 街道地址:

City 城市:

State 州:

Zip Code 郵政編碼:

At home, our family mostly speaks 在家裡，我們家大多會說的語言:

Page 3 of 3

Agreement to have Springboard Use Your Child's Image, Audio and First Name 同意讓 Springboard 使用您孩子的圖像、音頻和名字

I give permission for any photograph, image, direct quotes, voice, video or other recording, in all forms, and the first name of my child to be published and distributed in any media for promotional or informational purposes in connection with Springboard Collaborative and I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use 我允許任何形式的照片、圖像、語音、視頻或其他錄音以及我孩子的名字在任何媒體上公開和發布，用於與 Springboard Collaborative 相關的宣傳或信息目的；並且我知曉不會因此類使用而支付給我任何的版費、使用費或其他補償

Yes 同意No 不同意Sometimes we request photos of teachers and students in action to show our program at work! In a virtual world, photos might include a screenshot of a zoom class or of a celebration at the end of the program. In person photos might include students reading independently, with their parents or with their teachers. These photos are usually used for data reporting, future funders and/or for promotional materials about Springboard. The only identifying information would be the child's first name but nothing else (i.e. not their last name, address, etc.).

Agreement for Springboard to Text You 向您發送短信的協議

I agree to receive text messages from Springboard Collaborative, including workshop reminders, reading reminders and tips from Springboard Connect, and surveys. I can stop receiving these messages anytime by texting STOP. I accept the Connect Terms and Conditions and Privacy Policy 我同意接收來自 Springboard Collaborative 的短信，包括來自 Springboard Connect 的研討會提醒、閱讀提醒和技巧以及調查。我可以隨時通過發短信 STOP 來停止接收這些消息。我接受 Connect 條款和條件以及隱私政策

Yes 同意No 不同意

Agreement for Data Use 數據使用協議

本人同意 Springboard 使用此表格中的資訊以及我的家人參與此計劃的資訊，以 (1) 確保本人可以參與本計劃（即收集我家人的出勤率和學生的評估數據）以及 (2) 報告本計劃的結果。本人理解 Springboard 將在報告時刪除能識別本人家人的所有資訊，例如我們的姓名或聯絡資訊。我明白，在計劃結束後，我有權通過直接聯繫 Springboard 來要求將我的信息從 Springboard 的數據系統中刪除。

Would you like to be contacted with future opportunities to share your feedback and suggestions to improve our programs? 您是否希望在未來有機會與您聯繫，分享您對改進我們的計劃的意見和建議？

Yes 是No 否

Parent Agreement 家長協議

I understand the nature of Springboard Collaborative program and participation is voluntary. I understand that Springboard Collaborative is not responsible for loss, damage, illness, or injury to person or property as a result of participation in the program. I hereby release and discharge Springboard Collaborative and its officers, employees, agents, and volunteers from any and all claims for injury, illness, death, loss, or damage as a result of program activities. 我了解 Springboard 協作計劃的性質，並且知道參與是自願的。我了解 Springboard Collaborative 不對因參與該計劃而造成的人員或財產損失、損壞、疾病或傷害負責。我特此免除 Springboard Collaborative 及其管理人員、員工、代理人和志願者因該計劃活動而導致的任何和所有傷害、疾病、死亡、損失或損害的索賠。

該計劃由州教育總監辦公室 (OSSE) 資助。我在此同意 Springboard Collaborative 將我孩子教育記錄中的個人身份信息（包括入學、出勤、評估數據和定性反饋）安全地發布給 OSSE。