B.E.L.I.E.V.E. After School Program
BVE Extended Learning Intervention & Enrichment for a Valued Education 707.994.2272
CHILD'S INFORMATION
Child's First Name
Your answer
Child's Last Name
Your answer
Birthdate
MM
/
DD
/
YYYY
GRADE
Parent's Name
Your answer
Physical Address
Your answer
MAILING ADDRESS
Your answer
City
Your answer
Zip
Your answer
HOME PHONE
Your answer
MOM'S WORK PHONE
Your answer
FATHER'S WORK PHONE
Your answer
MOM'S CELL
Your answer
FATHER'S CELL
Your answer
CURRENT EMAIL ADDRESS
Your answer
Primary Language
Student lives with:
Does you child have any of the following
YES
NO
IEP
504 PLAN
HOW WILL YOU CHILD BE GETTING HOME:
Person(s) authorized to pick up your child/Emergency Contacts: (Person must show picture I.D.)
Name:
Your answer
Relationship
Your answer
Phone
Your answer
Name:
Your answer
Relationship
Your answer
Phone
Your answer
Name:
Your answer
Relationship
Your answer
Phone
Your answer
Name:
Your answer
Relationship
Your answer
Is your child under medical care or taking any medications?
Required
Will medication need to be dispensed during program hours?
Required
Does your child have any allergies, use an epipen, inhaler, etc:
If you marked yes please explain
Your answer
FAMILY HEALTH CARE:
Physician's Name
Your answer
Physician's Phone Number
Your answer
Health Insurance:
Your answer
EMERGENCY TREATMENT AUTHORIZATION:
By check yes under this section, you are giving Physician or Emergency Personal permission for appropriate emergency treatment if the situation occurs.
Media Release
Do you consent to allow your child to be used in any media publication, print or digital media?
The Konocti Unified School District may create and/or publish photographs, video and audio recordings of my child, as well as written or recorded oral descriptions and multi-media presentations of my child and their school projects.The District may publish these materials in any of several media formats such as radio, television, internet, newspapers, communication boards, classrooms,yearbooks, social media, school brochures, at educational conferences, on media including cassette tape, CD-ROM, DVD, and digital format.Any recordings of my child by the school remain the sole property of Konocti Unified School District.The making of or the use of any visual recordings of my child by the school or by the District under this agreement will be without any compensation.
Required
Lake County Office of Education/ASES Afterschool Program:
Matching Funds: Proposition 49/ASES funds require a 33% match for our grant. This match can be either in-kind or cash. We are thankful for your partnership in making sure that your monthly fees are paid by the 5th of each month. (Suggested fee for each student is $75.00 a month)
NO FAMILY WILL BE DENIED ENROLLMENT FOR INABILITY TO PAY A FEE.
I understand parent fees are used as a match.
I volunteer to pay the following amount every month for my child(ren) enrolled in the program.
Your answer
I am unable to pay a voluntary fee
I am able to volunteer each month for 1 hour per week toward a voluntary match to waive the months fee.
PARENT SIGNATURE
By submitting this form you are electronically signing The B.E.L.I.E.V.E. After School Program Form:
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