2023/2024 Temple Hill Elementary               Student Information Enrollment Form
Cost:  Full Week (4-5 Days) $55.00
           Flex Week (3 or Less Days) $40.00
           Express Pick-up (2:30-3:30) $30.00
           

All payments will be done through ACH withdrawal on-line payments with Procare.

Program Time: 2:30-5:00
* WILL FOLLOW SCHOOL CALENDER

PRORATED WEEKS:
August 9-12 $40-Flex
November 20-21  $40-Flex
January 3-5 - $40 -Flex

*If your child is enrolled in program you will be charged for their spot whether they are present or not.  

If you decide to remove child from the program a two week notice and unenrollment form must be filled out so billing will stop.  

Program Enrichment Offerings-1st 9-Weeks August 10-Oct.13,2023
Monday- Bulldog Archers or Walks n Wags
Tuesday- Math Mutts or Arff and Craft
Wednesday-Tail Wagging Craft or Bulldog Builder
Thursday-Robo Dogs or Bulldog Scholars
Friday-Downward Dog or The Zoomies

All forms are located on the Afterschool link on the Barren Co. Web page
Please complete all information.

Site Coordinator -Kasandra Dillard
                               ph# 270-579-6004
email: kasandra.dillard@barren.kyschools.us


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Email *
Procare Text Messaging Network:  In order to stay up to date on events and receive notifications about after-school, we need to link your network with your Procare account.
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Date of Enrollment *
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STUDENT First, Middle and Last Name *
Student Address *
Date of Birth *
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Gender *
Age *
Grade *
Mother's/Guardian's Name *
Mother's/Guardian's Phone Number *
Mother's/Guardian's Email *
Father's/Guardian's Name *
Father's/Guardian's Phone Number *
Father's/Guardian's Email *
Parent's Martial Status *
Are there any Court Orders, Decrees or Agreements in regard to child's custody or physical possession? *
Desired Start Date *
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Please select a which plan your child will be attending.  If on Flex and your child stays more than 3 days you will be charged for Full week.   *
By clicking on the "I accept" button you understand  if your child is enrolled in the afterschool program you will be charged for their spot whether they are present or not.  Also you must give a 2 week notice and fill out the unenrollment form if you want to remove your child from the afterschool program and stop billing charges.   *
Please mark what you want your child to work on during our homework help time.   *
Enrichment  offerings-Please click on the enrichments that your child would like to attend.  The enrichment is based on the 9-Weeks.  1st 9-weeks (Aug. 10-Oct. 13, 2023)  Please choose only one activity per day. *
Required
PICK UP INFORMATION:   Please list all individuals,  relationship and phone numbers that are authorized to pickup the student. INCLUDE PARENTS/GUARDIAN INFORMATION *
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Emergency Contact Name and Phone Number (Please list in order to be called 1, 2, 3 etc...)  INCLUDE PARENT/GUARDIAN INFORMATION *
Are immunizations up to date? (You are required to submit a copy to the center before your child can attend. ) *
Current/Preferred Doctor  NAME *
Current/Preferred Doctor ADDRESS *
Current/Preferred Doctor PHONE NUMBER *
Current/Preferred Dentist NAME *
Current/Preferred Dentist ADDRESS *
Current/Preferred Dentist PHONE NUMBER *
Current/Preferred Hospital NAME *
Current/Preferred Hospital ADDRESS *
Current/Preferred Hospital PHONE NUMBER *
Emergency Medical Authorization:  A parent/guardian must provide Barren Beyond the Bell consent for emergency medical treatment to be initiated for their child in the event of an emergency.  A parent/guardian may also refuse to grant consent.  If you would like to deny consent, please contact Sonya Davis (sonya.davis@barren.kyschools.us) *
In the event reasonable attempts to contact me or a second parent/guardian at the members listed in my emergency contact information have been unsuccessful, I hereby give my consent for: The administration of any treatment by a physician or dentist have listed on the next page, or in the event the designated preferred physician is not available, by another licensed physician or dentist. *
Please list any medical conditions, allergies, or medicine that our facility needs to know about the student. *
Please check any that apply *
Required
I give permission for my child's image, voice, or written comments to be included in evaluations, pictures, newsletters and marketing pieces associated with the program. Barren Beyond the Bell may use these indefinitely, without limitation of obligation for the purpose or promoting or interpreting Barren Beyond the Bell programs. *
We may show PG rated movies in our program.  Do you consent for your child to watch? *
I give my permission for my child to use all of the equipment and participate in all activities of the childcare programs. *
I understand that Barren Beyond the Bell assumes no responsibility for injuries or illnesses which may occur as a result of my child's physical condition or resulting from his/her participation in any athletic event, sports programs, and the use of any equipment, exercise or other activities. *
I acknowledge on behalf of myself and my dependents that I assume the risk for any injuries or illnesses which may result from activities.  I hereby release and discharge the Barren Beyond the Bell, it's agents, servants, and employees from any and all claims for injury, illness, loss or damage, which my child may suffer as a result of his/her participation in the childcare programs. *
I understand that Barren Beyond the Bell is not responsible for personal property lost or stolen while participating in the program.  My child is responsible for all of his/her belongings. *
I understand that the Barren Beyond the Bell is not responsible for anything that occurs as a result of false information given by a parent or guardian. *
I have read and understood the contents of the 2023-2024 Parent Notebook and agree to all the terms that are covered in the manual.  I understand that my signature indicates that I have been previously made aware of all policies, procedures, and guidelines referenced in the notebook concerning this program.  I have read and fully understand these policies and authorization statements.  I do hereby give such authorization as indicated or document understanding of specific policies. *
By signing electronically below, you agree to acknowledge and adhere to all of the policies and procedures associated with these programs.  These policies and procedures are outlined in detail in the 2023-2024 Parent Handbook. *
I understand that there is a late fee of $1.00 per minute/ per child for any child left after the end time of the program.  Once attendance has been submitted for the week, we will go into ProCare to bill accordingly.   *
By clicking on the accept BUTTON I understand that payments will be automatic withdrawn on Friday of each week through your Procare account.  If the payment is returned there will be $50. return ACH Decline charge.   *
I understand that the Barren Beyond the Bell program will follow the local school schedule.  If the children are scheduled to be off from school for the day our child care programs will NOT be available. *
I understand that under no circumstances will a child be able to bring their own toys or other personal items, which include but are not limited to: personal electronic devices, cell phones, card games, etc. If my child does so, the staff will hold the item and return it to the parent/guardian at the end of the day. *
I understand that my child(ren) must be signed in and out of the program daily.  This is a program requirement and must be done every day.  If someone else picks up my child they will need to complete the sign in/out sheet and also provide staff with identification. *
I understand that if my child will be absent from the program I need to call or email the Barren Beyond the Bell staff prior to the start of the program. *
I understand that if my child is absent from the program, I will be billed for their spot even though they did not attend. *
Are you interested in the Child Care Assistance Program? If you meet any of the following conditions you may be eligible for the CCAP program.  - Work an average of 20 hours per week for a single parent and 40 hours combined for a couple.  - A teen parent attending high school or pursuing a GED.  - Currently participating in the SNAP Employment & Training Program.  - Adult who is a full time student enrolled in a certified trade school or an accredited college or university.  - Participate in Kentucky Works activities.    - Need Child Care as a support for child protective/preventative services.   Please go to the following website to apply: http://kynect.ky.gov  *
By clicking on the "I accept" button. you are agreeing to your electronic signature.  please click the appropriate box. *
A copy of your responses will be emailed to the address you provided.
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