ASEP Enrollment Form 2021-2022
Mt. Carmel Elementary
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Email *
School *
Student legal Name ( Last name, First name) *
Student Date of Birth *
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Student Number *
Grade/Teacher *
ASEP start date *
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Custodial Mother's Name - Email address and contact telephone number *
Custodial Father's Name - Email address and contact telephone number *
Legal Guardian Name - Email address and contact telephone number *
If you or someone in your residence is a full-time benefited Henry County Schools employee please provide name, employee number and employment location. *
Name of Emergency Contact and Telephone Number:  (In case parents/legal guardian cannot be reached) *
Please list all allergies and medications, dosage and time of dosage. *
Does your child require an Epi-Pen for any allergy? *
Are there any medications that your student will take during the Afterschool Enrichment Program? *
Please list all persons authorized to pick up your child from the afterschool program including the parents/legal guardians. NOTE: Only the enrolling parent can make changes to the authorized pick up list. *
I understand that weekly tuition is $50.00 ($33.50 for HCBOE employees and is due the Friday before the week of service and my student may be dismissed from ASEP for non-payment.  ASEP  does not accept CASH.  Weekly tuition must be paid by check, money order or online www.myschoolbucks.com.  ASEP is located under the "School Store" tab. *
Required
I understand that a one time registration fee of $25.00 (non-refundable) is due before my student may attend ASEP *
I understand that ASEP operates only when school is in session and that my student must be picked up by 6:00 pm.  I also understand that a $1.00 per minute after 6:06 pm will be charged and is due at pick up *
Required
I understand that discipline must be a collaborative responsibility with ASEP staff, student and parent.  Disciplinary actions my be imposed ranging from temporary removal from an activity to suspension/dismissal from the program, depending on the severity of the infraction.  Severe infractions may necessitate dismissal on a first offense.  The ASEP Director will make the final decision of dismissal for severe infractions. *
I understand that time and assistance if needed is given for the completion of homework, however, the ASEP staff isn't responsible for checking or insuring accuracy of completion of homework assigned. *
I understand medication will not be given to my student during ASEP (including aspirin and cough drops unless a Medical Authorization Form is completed by parent or given and on file with ASEP. *
Required
I authorize the ASEP staff, in case of a 911 emergency, to allow medical personnel to administer medical treatment. *
I understand that on occasion ASEP shows G/PG movies. *
Required
Name of person completing enrollment form and relationship to student: *
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