21st CCLC WCES Afterschool Application 24-25

  • PLEASE COMPLETE ONE FORM PER CHILD
  • Location:  Waynesburg Central Elementary School
  • Grades: 1 - 5 (entering for the 24-25 school year)
  • Dates: September 16– May 22, 2025 - rolling enrollment - To begin 9/16, app. due 9/9
  • When: Monday – Thursday (3:15 - 5:45 pm)
  • Price: FREE to attend with FREE transportation to drop-off points

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Student Name (First, Last)
 *
Homeroom/Teacher Name *
Sibling Name (s) enrolled/ing in the program
Birthdate
 *
MM
/
DD
/
YYYY
Gender *
Race *
Ethnicity 
2024-2025 Grade  *
Student Home Address
 *
Is your child permitted to be photographed?
*
Parent(s)/Guardian(s) Emails:
*
Mother’s Name/Legal Guardian
 *
Telephone Number
 *
Work/Alternate Telephone Number
 *
Father’s Name/Legal Guardian
Telephone Number
Work/Alternate Telephone Number
Emergency Contact Person(s) Name/Telephone Number
 *
Name/Telephone Number of the person to whom the child may be released
 *
Name of child’s physician / Medical care provider
 *
Telephone Number
 *
Address
 *
Disabilities (if any)
Allergies (including medication reactions)
Medical/Dietary information (Necessary in an emergency)
Medication/special conditions
Additional information/special needs
Health insurance or medical assistance benefits
 *
Health or Medical Insurance Policy Number (required):
 *

Other approved individuals authorized to pick the student up:

By checking all of the boxes below, I give consent for my child to participate or engage with each of these activities: 
 *
Required

Attendance/ Dismissal: 

Daily dismissal time is promptly at 5:45 PM. While early dismissals may occasionally happen, please be advised students will miss out on the full benefits of the program and can be disruptive.

Students are strongly encouraged to attend Monday through Thursday, other extracurricular activities may interfere, please provide an updated schedule often to plan free daily dinner counts. If you are not able to attend, please contact Ms. Yenchik via class dojo as soon as you are aware of a potential absence. Please check all of the days you plan to regularly attend.

If you can not attend all of these days, please let us know why so that we may keep track of the reasons to inform our state funding source.

To participate in the 21st CCLC Afterschool Program through Central Greene School District at Waynesburg Central Elementary School, I give permission for pertinent information from my child’s academic and attendance records to assist the 21st CCLC program tailor fitting to the educational needs of students participating in the program. This includes 1st, 2nd, 3rd, and 4th Nine Weeks Report Cards, Discipline Reports, PSSA test scores, local level test scores, and Individualized Education Programs (IEPs). Your signature also allows our External Evaluator, Stacey Papa, to use the student academic and attendance records listed above to provide external evaluation services. All student information will be kept confidential. Your signature additionally indicates your understanding that the same Internet policy binds students during the school day. Finally, your signature indicates that you will read and follow the 21st CCLC Handbook sent home with your child after they begin the program.  

In lieu of a signature, my typed name and date guarantees my understanding of the above statement.

 *
I want my child to be bussed to a drop off point after the program.  *
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