'21-'22 Cornell After-School Registration

Program runs Mondays - Thursdays
(T) September 7th - (Th) May 19th
Funding provided by 21st Century CLC Grant
Please call 715-861-6960 for more information.


Please complete an enrollment form for each student

- Each enrollment takes approximately 15 minutes.
- Partial or incomplete forms cannot be saved.
- Pressing "BACK" at anytime, this will ERASE all information you've entered to that point.
- Mobile device will work. Formatting will be better on a traditional computer screen.
- Answer all questions with a red star. Those without a red star you may leave blank.
- Please plan on meeting with the Site Coordinator prior to start.
(This may be done during the Open House/ Resource Fair on August 23rd.)

Thank you for enrolling online.

Your input and suggestions are always welcome!
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Email *
Clear selection
New or Returning
Additional Email (Work, other parent, etc.)
When do you prefer to meet with Site Coordinator for orientation? (If other than August 23rd, please provide a couple of dates and times that would work for you.) *
I understand that Cornell After-School Program will be held immediately following the final school bells at the Cornell Elementary school for students in K-5th grade and at the Cornell Middle/High School for students in 6th-8th grade, that mask-wearing will follow school guidelines, and that day-school protocol will be followed during programming. Students are expected to have safe and respectful behavior at all times. *
Student First Name *
Student Last Name *
Student Address *
City *
Student Date of Birth *
2021-2022 Grade/Teacher (No PreK After-School) *
Bus Number / Driver *
Days Attending (Reminder: No Program on Fridays) *
Pickup Time - All students must be picked up by 5:45 each evening to allow for cleaning and sanitizing. *
Requested Start Date: Must complete by 8:00 p.m. Wednesday of the week prior to requested start date to allow time for processing. After-School begins September 7, 2021. *
No After-School Dates: I understand there will be NO After-School Program when school or after-school activities are cancelled for any reason. *
Getting Home *
Walk - List walking buddies here.
Picked Up - Please list contact information if anyone OTHER than parents or guardians will be picking student up.
Ride Van - List details for driver here.
Clear selection
Student Strengths (Check all that apply.)
Social Studies
Classroom Behavior
Social Skills
Attendance and/or Being on Time for School
Father / Guardian
First Name *
Last Name *
Address *
City *
Mobile Number *
Home Number *
Place of Employment *
Work Number *
Mother / Guardian
First Name *
Last Name *
Address *
City *
Mobile Number *
Home Number *
Place of Employment *
Work Number *
Emergency Contact
First Name *
Last Name *
Mobile Number *
Home Number *
Work Number *
Clinic/Hospital *
Telephone Number of Clinic/Hospital *
Name of Doctor or Primary Care Provider
Medical Conditions of Student *
Condition Triggers
Signs or Symptoms to watch
Consent to emergency medical care for my student if I cannot be reached immediately. *
Additional Medical Notes
After-School Cancellations: A group email will be sent to primary addresses provided. If I have no email, I will be sure to check the school webpage, and Facebook. I understand that my electronic signature below shows my agreement with all After-School policies and procedures and provides my consent to all items listed on After-School forms. *
Donations Completely Optional - No Fees Required *
Optional Additional Information
After-School Program Polices
NO Registration Fee!
There are no longer any After-School Program fees; only optional donations for participation and transportation.

PROJECT SOAR – Support, Opportunity, Achievement, Responsibility
Students and families are part of PROJECT SOAR! One donation option for After School Program is $50 per student per year. Our goal is for every family to have a sponsor at this level. We will help match local sponsors with families anonymously.

Monday – Thursday
September 7, 2021 - May 19, 2022. Students who participate in After-School Program will have a wide variety of exciting opportunities. The following schedule is a sample guideline.

Time Activity - Place
3:16 Walk to Homework / Skills Practice
4:15 Snack
4:30 Academic Enrichment - Rooms / Outdoors / Kitchen / Park / Etc.
5:20 Walkers & First Van Depart (Earlier mid-winter for light) 5th Street E1 Exit
5:30 Extended learning plus P.E. - Gymnasium / Outdoor as weather permits
5:45 Dismissal - Student Pick up at 5th Street E1 Exit
6:00 Special Classes & Events - See Community Education Brochure to Sign Up

Family Education Director, Site Coordinator, Academic Advisor, Teachers, Adult Leaders, & High-School Helpers.

School procedures will be followed. Be sure to provide up-to-date contact information and check Facebook, school webpage & email regularly when weather is changing.

Attendance / Communication
Notification of absence in advance is required. Any sport or extra-curricular activity which effects the After-School schedule or pick up of an enrolled student needs to be clearly communicated to staff prior to the start of said activities.

Van transportation will be provided only for those with no other option. One donation option is $30 per quarter. Students riding the van must comply with the rules as indicated in the student handbook. Transportation is a privilege, and misbehavior will not be tolerated. The first van route will depart beginning at 5:20 p.m. while the second route (if needed) will depart when the first returns and so on.

Student records will be kept confidential. Parent/Guardian must inform staff promptly of any changes to medical information, or allergies.

Excellent behavior is expected from all students. Students who display disruptive behavior will be given three written notifications and then will be dismissed from the program for a minimum of one week at a time. At staff discretion, some behaviors may result in automatic dismissal from program. School rules of conduct apply during After-School Program.

Students will be allowed to call home at the discretion of the site director.

Personal Items
If any personal item is seen by any After School Program staff as a distraction to program activities, that item will be placed in the CLC office until the end of the day. Students may not use cell phones or other electronic devices at After-School Program without prior consent from director.

Suitable snacks will be served daily to children who participate in the After-School Program.

School procedures will be followed.

Dress Code
Masks will follow school guidelines. Students will spend time outside in the After-School Program, weather permitting. Children who are not properly dressed may miss outside activities. A wide variety activities are offered, some of which can get pretty messy. It is possible for clothes to get dirty or even stained during project times. After-School Program will follow the guidelines of the regular school day concerning weather.

Field Trips
Trips will be included in part of curriculum. Signing the permission page allows your child to participate in local trips. A separate form will be sent home for trips requiring transportation. Fees may apply for voluntary trips.

Staff does not distribute medicine of any kind.

● Permission to access the Internet and e-mail:
Your daughter/son will be permitted access to networked computer services with expectations to match school-day usage. (Please see student handbook – available on school website). The District uses a filtering system that generally blocks student access to inappropriate sites. If you do not want your student to be allowed this access, you must inform the CLC program, in writing, within 14 days after the date of enrollment.

● Permission to photograph, videotape and audio tape:
I understand that my child’s image may be captured at CLC program and I agree to allow these photographs, videotapes and audiotapes to be used for all CLC purposes including but not limited to print and digital media such as newspapers, CLC Webpage and FACEBOOK PAGE, etc..

● Permission to participate in surveys and testing for data collections purposes:
I understand that my child may be asked to complete survey information and participate in testing regarding the CLC program for evaluation purposes and I agree to allow my child to participate in such.

● Permission to speak with school staff regarding child’s progress:
I understand that the CLC focuses on improving education and I agree to allow the CLC staff and school staff to exchange information, academic progress, and program planning at my child’s school regarding my child’s grades, conduct, and attendance records.

● Permission to attend After School field trips:
I understand my child may attend After School “walking” Field trips, and that separate permission slips will be sent home prior to field trips requiring transportation.

● Permission to watch G or PG rated films:
I understand my child may watch and discuss G or PG rated movies on occasion at After-School Program for the purpose of education or celebration. Any movie or clip to be shown with another rating will be accompanied by a permission slip with my signature before my child is allowed to watch.
I have read, understand, give consent, and agree to all After-School Program policies and procedures. Type name of parent/guardian completing form. This will serve as your Electronic Signature. *
A copy of your responses will be emailed to the address you provided.
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