New York State 21st Century Community Learning Centers (CCLC) After School Program Enrollment Form 2024-2025 School Year 
Please complete one form per student to enroll in after school programming for Schenectady City School District 
Sign in to Google to save your progress. Learn more
Email *
Students Preferred Name 
Student's First and Last Name *
Date of Birth  *
MM
/
DD
/
YYYY
Gender  *
Student's Home Address *
Home Phone Number  *
Language(s) Spoken at Home: *
Student ID Number 
Racial/Ethnic Group  *
Attending School  *
Student's Primary Teacher
Name of Person Enrolling Student  *
Relationship to Student  *
Address of Person Enrolling the Student (if different than student)
Phone Number of Person Enrolling Student  *
Email Address of Person Enrolling Student  *
Emergency Contact: Primary 1 Contact Name  *
Emergency Contact: Primary 1 Contact Phone Number
 *
Emergency Contact: Primary 1 Contact Relationship to Student
 *
Emergency Contact: Primary 1 Contact Authorized to Pick Up Student 
 *
Required
Emergency Contact: Primary 2 Contact Name 
Emergency Contact: Primary 2 Contact Phone Number
Emergency Contact: Primary 2 Contact Relationship to Student
Emergency Contact: Primary 2 Contact Authorized to Pick Up Student 
Emergency Contact: Secondary Contact Name 
Emergency Contact: Secondary Contact Phone Number
Emergency Contact: Secondary Contact Relationship to Student
Emergency Contact: Secondary Contact Authorized to Pick Up Student 
Release of Student at Dismissal: I give my child permission to walk alone at dismissal: *
Required
Release of Student at Dismissal: If no, my child will be picked up after school by me or one of the following individuals (Please list authorized pick up names, phone numbers, and relationship to student):
My Child MAY NOT be Picked up by the Following Individuals (Please list name and relationship to student): 
If I am not Available During Emergencies, my Child may be Released to one of the Following Individuals (Please list name, phone number, and relationship to student): *
Does your child have any existing health conditions including allergies, asthma, diabetes, seizure disorders, etc.? (If yes, please list conditions below):  *
Does you child use any medicines and/or specific instructions for their health needs? (If yes, please list below):  *
Does your child have a vision condition?  *
If yes to the above question, and your child needs aids at school other than wearing glasses or contacts, please describe the assistance needed below: 
Does your child have a hearing condition?  *
If yes to the above question, and your child needs aids at school other than wearing a hearing aid, please describe assistance needed below: 
Does your child have any physical limitations?  *
Is your child able to participate in physical education class at school with no limitations? *
If no to the above question, please list your child's activity limitations below: 
Is your child on any other medications not listed above?  *
If yes to the above question, please list your child's current medications below:
Does your child have special diet needs, other health needs, or behavioral/emotional needs? *Please note medications taken or administered at the program will need written parent/guardian consent and health care provider order.
Please check with program director/site coordinator for details.
 *
If yes to the above question, please describe below: 
I give my child permission to enroll and participate in the 21st CCLC program and/or other After School Program. *
I understand that following agreements and consents are not pre-conditions for approval to participate in the 21 st CCLC program and/or Other After School Programs.
 *
I consent to emergency medical treatment for my child.
 *
I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by the Schenectady City School District After School Programs. I also grant the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release and its agents and employees from Schenectady City School District After School Programs all claims, demands, and liabilities whatsoever in connection with the above.
 *
I consent for my child to take part in field trips, away from the program site, under supervision.
 *
I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips.
 *
I provided information on my child’s special needs to the program to assist in the safety of my child.
 *
I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with 21st CCLC and/or Other After School Programs’ staff on a need-to-know basis for my child’s educational benefit.
 *
I agree to review and update this information whenever a change occurs and at least once every year.
 *
I agree to talk to the program staff about my child’s progress and participation in the 21st CCLC program and/or Other After School Programs.
 *
If at any time I change my mind about my child’s participation (any or all aspects), I will contact the site coordinator.
 *
I understand that my child’s academic, behavioral, attendance, and engagement information will be shared with the New York State Education Department and its lawful contractors, to measure and evaluate the quality and implementation of the local 21st Century Community Learning Center (21st CCLC) program and/or Other After School Programs as well as the effectiveness New York State’s programs in supporting student growth, as required by Title IV, Part B of the Every Student Succeeds Act (ESSA) [see generally sections 4205 (b) and 4203 (14)].

I understand that my child and I may be asked to participate in surveys and/or interviews about the 21st CCLC program and/or Other After School Programs and related effects. Only check the following box if you would like to opt-out and not participate in surveys and/or interviews.
By signing below, I certify that all information (above) is true and correct to the best of my knowledge. (please type first and last name as form of electronic signature): 
 *
Today's Date:  *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Schenectady City School District.

Does this form look suspicious? Report

Google Forms