Midlands After School Care Enrollment Form
Due to certain restrictions, please fill out one Google form per student attending after school care.

After School Care runs until 6:00pm Monday through Friday. The fee is $170/month for one student and a discount for siblings. For discounted rates/daily rates, please see payment information sheet.

Student Information
Student's Full Name *
Your answer
Student's Complete Address *
Your answer
Primary Home/Cell Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Grade Level for 2017-2018 School Year *
Student lives with: *
Required
Please list any allergies and/or documented medical restrictions the student has: *
Your answer
Contact Information
"Contact 1" and "Contact 2" should be the parents/legal guardians.
Contact 1 Name *
Your answer
Contact 1 Phone Number(s) (please include best number to reach you at during after school care hours) *
Your answer
Contact 1 Place of Employment *
Your answer
Contact 1 Place of Employment Phone Number *
Your answer
Contact 2 Name *
Your answer
Contact 2 Phone Number(s) (please include best number to reach you at during after school care hours) *
Your answer
Contact 2 Place of Employment *
Your answer
Contact 2 Place of Employment Phone Number *
Your answer
Emergency Contact Information
***Other than Contacts One and Two, please list other persons permitted to remove your child from the after school care program.***
Emergency Contact 1-Name *
Your answer
Emergency Contact 1-Relation to Student *
Your answer
Emergency Contact 1-Phone Number *
Your answer
Emergency Contact 2-Name *
Your answer
Emergency Contact 2-Relation to Student *
Your answer
Emergency Contact 2-Phone Number *
Your answer
Emergency Contact 3-Name
Your answer
Emergency Contact 3-Relation to Student
Your answer
Emergency Contact 3-Phone Number
Your answer
Emergency Contact 4-Name
Your answer
Emergency Contact 4-Relation to Student
Your answer
Emergency Contact 4-Phone Number
Your answer
GREEN Charter School After School Care Internet Use
Green Charter School has internet accessibility for students and uses and internet filter. Parents must give permission for their students to use the internet during after school care. Below you will be asked to agree or disagree to give your student permission to use the internet during the after school care program for educational purposes, connected with school assignments.

Home/outside devices are not permitted in after school care. The internet will only be used at school through the computers and devices owned by GREEN Charter School, which are already equipped with internet filters.

*NOTE: Internet use is typically reserved for students in 4th grade and above, however, all grade levels may periodically visit the computer labs during after school care throughout the year.

I give my student permission to use the internet during after school care. *
I understand that home/outside devices are not permitted in after school care. *
Consent for Treatment
In case of an emergency, accident or serious illness/injury in which the school may be unable to reach you as the parent, we need your consent to make necessary arrangements to provide care and treatment for your child.

Please read through the below information and agree to consent of treatment.

I hereby give GREEN Charter School consent to contact medical professionals and make necessary medical arrangements for my student in the even that I cannot be contacted. *
I hereby give GREEN Charter School consent to arrange transportation of my student in the event that they are unable to remain on campus. *
I hereby give GREEN Charter School consent to communicate with the individuals listed on the emergency contact list regarding my student's immediate medical needs, should I be unreachable. *
Required
I authorize first aid and/or emergency medical treatment for my student in the event of injury or illness. *
I voluntarily agree to expressly assume all risks which may result from the health and fitness activities or in any way related to my student's participation in the after school care program. *
General Release of Liability
I hereby release and forever discharge community education, the South Carolina Public Charter School District, their officers, servants, agents and employees, from all claims and demands, rights and causes of action of any kind the undersigned now has and hereafter may have an account of or in any way arising from personal injuries known or unknown to the undersigned at the present time and property damage resulting or that results from any occurrence which may happen to my student during the GREEN Charter School After School Care Program. *
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