21st Century Community Learning Center Creating Rural Opportunities Partnership (CROP) APPLICATION AND CONSENT FORM
CROP BEGINS SEPT 21 AND WILL BE VIRTUAL UNTIL FURTHER NOTICE .... all questions require an answer please choose n/a or none if need be.
Sign in to Google to save your progress. Learn more
Email *
Child's Full Name:
Child's DOB
Parents /Guardians' Full Names:
Mailing Address:
Physical Address:
Mother/Guardian - Home #:
Mother/Guardian - Cell#
Mother/Guardian - place of work :
Mother / Guardian work phone number
Mother/ Guardian Email
Father /Guardian - Home #:
Father/Guardian - Cell#
Father/Guardian - place of work :
Father / Guardian work phone number
Father/ Guardian Email
Emergency Medical Information Physician Name:
Emergency Medical Information Physician Phone Number :
In the event that I, or my child's physician cannot be reached in an emergency, I hereby give my permission to the physician/hospital selected by the CROP Program to secure proper medical treatment for my child
Allergies and/or Special Needs (Please list any allergies to foods, bees, etc., and/or any special needs) Allergy or Special Need (n/a for none )
First - Emergency Contacts / Authorized Adults for Student Pickup WHEN CROP RESUMES Name, Phone, Relationship to child
May this person pick up your child?
Second - Emergency Contacts / Authorized Adults for Student Pickup WHEN CROP RESUMES Name, Phone, Relationship to child ( please type n/a if none )
May this person pick up your child?
Bus Pickup/Drop off Locations: If your student will require bus transportation) WHEN CROP RESUMES Location (home, babysitter, etc.) Physical Address, list multiple if applicable.
When CROP resumes will your child be picked up by parent or authorized contact, bused home, or bused to an alternate location ? Please list in detail by day. Please note any change in the dismissal plan on a daily or permanent basis must be given to the site coordinator in writing by the parent or guardian.
CROP STUDENT DATA and EVALUATION CONSENT FORM ----------------------------------------------Dear Parents, Creating Rural Opportunities Partnership (CROP) after-school program is funded by the 21st Century Community Learning Centers grant. In order to monitor the effectiveness of the after school program and ensure its future success, an independent evaluator is conducting an ongoing evaluation. It is the intention of the evaluation to learn how these after-school services help students, and how they can meet the grant requirements. Any information we collect will be used only to assess the after school program and will not be made public. Participating in the evaluation will not affect your child in school, in the after-school program, or in any other way. We will not use your name or your child's name in any report. Please answer the following options: I give consent for access to my child's records for the sole purpose of data collection (including grades state assessment scores) for the Department of Education, in accordance with continued funding of the CROP Program. I understand that my child's name will not be used.
I give permission for my child to participate in surveys, focus groups or interviews (as ability and age allows) about the afterschool program and its effects including the Short-term Student Outcomes Survey
I give consent for my child to be photographed, or video-taped while in CROP for educational material, promotional articles or any other lawful purpose.
Parent/Guardian Memo of Understanding: I have been given access to a link to access a parent handbook at https://www.oncboces.org/Downloads/CROP%20Parent%20Handbook.pdf printed copy available upon request that provides information regarding the CROP Program, and I am aware of the policies explained within. I agree to comply with the policies outlined in the handbook, and will fulfill my responsibilities to provide current and accurate emergency information to CROP staff. I will encourage my child to participate fully and with appropriate behavior in activities and events planned by staff. I understand that failure to fulfill these requirements may result in my child becoming ineligible to remain in the program
I have reviewed the Student Memo of Understanding with my child : I understand that I am expected to learn and follow the CROP program rules. In the event that I choose not to follow the rules, I may have to leave the program. The policy for discipline will be: 1) Verbal warning. 2) Conference with Site Coordinator and parent/guardian. 3) Extended time out of program or release from the program. RULES TO REMEMBER: 1) Respect yourself 2) Show respect for adults and peers 3) Respect school property 4) Follow the school's rules of conduct 5) Be helpful to others in the program 6) Have Fun.
The CROP program will begin virtually this year. We will have daily video links to homework help, project kits that will be sent home periodically , and on-screen projects/ events with our staff and partners. We hope to resume conventional CROP in the future . I look forward to all being a part of this exciting program . Thank You- if you have any questions please email me at lvancleef@jeffersoncsd.org.
Please type your full name to confirm that you agree with all information provided here and that you will comply with the rules of the program. Type your full name and today's date .
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jefferson Central School. Report Abuse