ASEP Enrollment Form 2021-2022

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Mt. Carmel Elementary

Email *

School *

Student legal Name ( Last name, First name) *

Student Date of Birth *

YYYY

Student Number *

Grade/Teacher *

ASEP start date *

YYYY

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? *

Yes

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. *

Yes, I understand tuition is due the Friday before the upcoming week of service.

Required

I understand that a one time registration fee of $25.00 (non-refundable) is due before my student may attend ASEP *

Yes, I understand that the registration fee is due upon enrollment and non-refundable

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 *

Yes, I understand the late pick-up policy.

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. *

Yes I understand and will also explain to my student the rules on discipline

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. *

Yes, I understand

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. *

yes, I understand

Required

I authorize the ASEP staff, in case of a 911 emergency, to allow medical personnel to administer medical treatment. *

Yes, I understand that medical personnel may treat my student in a 911 emergency

No, I do not want medical treatment for my student.

I understand that on occasion ASEP shows G/PG movies. *

Yes, my student may view G/PG movies in ASEP

No, my student may not view G/PG movies in ASEP

Required

Name of person completing enrollment form and relationship to student: *

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