Virtual Arts Programs

Student Information
Student Name (Please Print)(required)

Cell Phone

Student Email (required)

Current School

Grade
9th10th11th12th

What Year Will You Graduate?

Date of Birth

Street Address

City/State/Zip code

Virtual Classes Offered (4 Week Program)
Photography (M/W)- Digital Photography; create your own images! Health Sciences Students ONLYFine Arts (M/W) – Create with paint, sculpture and mixed media!

Parent/Guardian Name

Relationship to Student

Parent/Guardian Primary Phone

BCAT Youth Intake Form-CONFIDENTIAL
Please fill out this section so we can get to know you better. We want to make sure you have the best possible experience at BCAT and these answers will help us understand how to serve you best. This form will only be shared with the Youth Program Staff, so please give us open and honest answers!

How did you hear about BCAT?

What other extracurricular activities do you participate in?

What are your interests?

Are you interested in attending college?
YesNo

If yes, What are you interested in studying? If no, What are your plans for after high school?

Are you currently working, where? OR Do you need help finding a part time job?

BCAT offers tutoring assistance to all participants in the Youth Arts Program. Tutors are welcoming and enthusiastic about helping you achieve your academic goals! Do you need tutoring with BCAT?
YesNo

Permission Form and Waivers for Parents and/or Guardian

I give my student permission to participate in the Buffalo Center for Arts and Technology programs.
YesNo

I understand that the BCAT has shared its Honor Code with my student and that any violations will be documented and
suspension may result if he/she consistently fails to comply with this code of conduct and the rules of the BCAT program. The Honor Code can be found at www.buffaloartstechcenter.org.
YesNo

I understand that BCAT maintains an attendance policy that expects students to communicate absences to their instructors. If a student misses 4 consecutive sessions without communicating with BCAT he/she will most likely be withdrawn from the class.
YesNo

I understand that Buffalo Center for Arts and Technology cannot be responsible for any of my student’s personal
possessions that he/she chooses to bring to BCAT programs.
YesNo

I understand that while at BCAT my student(s) will not view or download pornographic, racist, sexist, or inappropriate
materials from the Internet.
YesNo

I understand that for BCAT to improve, staff and/or professional external evaluators may make observations during activity times, conduct interviews, and administer questionnaires in which my child is asked about their experiences at BCAT. Professional evaluators and BCAT staff will have access to my son/daughter’s in-school behavior, attendance, grades and progress towards graduation throughout their high school and college career.
YesNo

I understand that photographs and videos may be taken during BCAT programming. I understand media and artwork produced by my child may be used for educational, funding, promotional or other purposes and may be displayed and sold on behalf of BCAT. I give BCAT my permission to use, in part or whole, the name, picture, performance, photography and/or taped voice for my child. I waive any right to inspect or approve the finished photograph or video or audio recording.
YesNo

I understand that my child will be working in programs, such as Visual Art, Videography, and Photography, where contact with mechanical equipment and/or chemicals may be involved. I understand that BCAT is not responsible for any items that are damaged, lost, or stolen. I understand that BCAT will supervise my child during program hours at its facility and on field trips. I am responsible for coordinating transportation for my child to get to BCAT and to get home from BCAT. I will set boundaries and consequences if my child leaves BCAT during program hours without my permission.
YesNo

This consent is to disclose student’s personally identifiable information within Buffalo Public Schools and Buffalo Charter Schools education records to support your student, track graduation progress and college readiness, and evaluate the BCAT program. The purpose of disclosing identifiable student education record information is to learn how well the BCAT program is working to make improvements and to assist students participating in the program. This will be done by monitoring school behavior, attendance, grades, and progress towards graduation throughout their high school career. With this information, BCAT staff will follow up with students to talk about their in-school progress and work with students in graduation and college enrollment. Such information shall not be published in a manner that will lead to the personal identification of the student. This information is used solely for evaluation and program management purposes and to improve the student’s learning and school performance and shall not be further redisclosed to third parties not named on this consent form without my/our prior written approval.

I agree and consent to the release of personally identifiable information from the education records of my child/ward named below,
YesNo

I understand that the educational records to be disclosed include:
• Attendance & Enrollment Information
• Classroom Performance
• Test Scores (M-STEP, SAT, etc.)
• Grade Reports
• Behavioral or Disciplinary Information
• Credits Earned

My consent is completely voluntary. If I agree, I may change my mind at any time. My decision to give or deny consent to my student’s educational records will not impact their enrollment in the BCAT program. By submitting this consent agreement, I agree that I have read and understood the above and consent to all the above statements.